Eur J Vasc Endovasc Surg (xxxx) xxx, xxx EJVES

Open Access

CLINICAL PRACTICE GUIDELINE DOCUMENT

European Society for Vascular Surgery (ESVS) 2025 Clinical Practice

Guidelines on the Management of Vascular Trauma5
Carl Magnus Wahlgren a,*, Christopher Aylwin a, Ross A. Davenport a, Lazar B. Davidovic a, Joseph J. DuBose a, Christine Gaarder a, Catherine Heim a,
Vincent Jongkind a, Joakim JørgensenIn a, Stavros K. Kakkos a, David T. McGreevy a, Maria Antonella Ruffino a, Melina Vega de Ceniga a,
Pirkka Vikatmaa a, Jean-Baptiste Ricco a,Karim Brohi a
ESVS Guidelines Committee b, George A. Antoniou, Jonathan R. Boyle, Raphaël Coscas, Nuno V. Dias, Barend M.E. Mees, Santi Trimarchi,
Christopher P. Twine, Isabelle Van Herzeele, Anders Wanhainen
Document Reviewers c, Paul Blair, Ian D.S. Civil, Michael Engelhardt, Erica L. Mitchell, Gabriele Piffaretti, Sabine Wipper

Objective: The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care
of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.
Methods: The guidelines are based on scientific evidence completed with expert opinion. By summarising and
evaluating the best available evidence, recommendations for the evaluation and treatment of patients have
been formulated. The recommendations are graded according to the ESVS evidence grading system, where the
strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.
Results: A total of 105 recommendations have been issued on the following topics: general principles for vascular
trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft
materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet,
abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric
vascular trauma. In addition, unresolved vascular trauma issues and the patients’ perspectives are discussed.
Conclusion: The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based
advice to clinicians on the management of vascular trauma.

Article history: Received 22 November 2024, Accepted 9 December 2024, Available online XXX
Ó 2024 The Authors. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

TABLE OF CONTENTS
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Summary of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2. Guideline Writing Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.3. Literature search and selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4. Evidence and recommendation grading criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.5. Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.6. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. Vascular trauma general considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1. Vascular trauma epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.2. General principles for vascular trauma care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

5
For a full list of the authors’ affiliations, please refer to Appendix B.
a
Guideline Writing Committee: Carl Magnus Wahlgren (Chair; Stockholm, Sweden), Christopher Aylwin (London, UK), Ross A. Davenport (London, UK), Lazar B.
Davidovic (Belgrade, Serbia), Joseph J. DuBose (Austin, TX, USA), Christine Gaarder (Oslo, Norway), Catherine Heim (Lausanne, Switzerland), Vincent Jongkind
(Amsterdam, the Netherlands), Joakim Jørgensen (Oslo, Norway), Stavros K. Kakkos (Patras, Greece), David T. McGreevy (Örebro, Sweden), Maria Antonella Ruffino
(Lugano, Switzerland), Melina Vega de Ceniga (Galdakao, Leioa, and Barakaldo, Spain), Pirkka Vikatmaa (Helsinki, Finland), Jean-Baptiste Ricco (Co-Chair, Poitiers,
France), Karim Brohi (Co-Chair; London, UK).
b
ESVS Guidelines Committee: George A. Antoniou (Manchester, UK), Jonathan R. Boyle (Cambridge, UK), Raphaël Coscas (Boulogne-Billancourt, France), Nuno
V. Dias (Malmö, Sweden), Barend M.E. Mees (Maastricht, the Netherlands), Santi Trimarchi (Milan, Italy), Christopher P. Twine (Bristol, UK), Isabelle Van Herzeele
(Ghent, Belgium), Anders Wanhainen (Uppsala and Umeå, Sweden).
c
Document Reviewers: Paul Blair (Belfast, Northern Ireland, UK), Ian D.S. Civil (Auckland, New Zealand), Michael Engelhardt (Ulm, Germany), Erica L. Mitchell
(Memphis, TN, USA), Gabriele Piffaretti (Varese, Italy), Sabine Wipper (Innsbruck, Austria).
* Corresponding author. Department of Vascular Surgery, Karolinska institutet and Karolinska University Hospital, 171 76 Stockholm, Sweden.
E-mail address: [email protected] (Carl Magnus Wahlgren).
1078-5884/Ó 2024 The Authors. Published by Elsevier B.V. on behalf of European Society for Vascular Surgery. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.ejvs.2024.12.018

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
2 Carl Magnus Wahlgren et al.

2.3. Who should perform vascular trauma surgery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

2.4. What technical skill set is required for vascular trauma surgery? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.5. When are endovascular therapies required for vascular trauma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.6. What approach to resuscitation should be used for vascular trauma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.7. Use of tourniquets for temporary bleeding control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.8. Resuscitative endovascular balloon occlusion of the aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.9. What diagnostic imaging should be used for the emergency diagnosis of vascular trauma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.10. European Society for Vascular Surgery grading system for arterial trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.11. How should perfusion be restored as an emergency in vascular trauma? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.12. Vascular shunts vs. definitive repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.13. Which technique should be used for vascular graft reconstruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.14. Which graft materials should be used for arterial reconstruction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3. Neck vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1. Penetrating neck injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1.2. Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1.3. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.1.3.1. Penetrating carotid artery injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.1.3.2. Penetrating vertebral artery injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.1.3.3. Penetrating cervical venous injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2. Blunt cervical vascular injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.2.2. Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.3. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.3.1. Blunt carotid artery injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.3.2. Blunt vertebral artery injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
3.2.3.3. Antithrombotic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.3.4. Surveillance of blunt cervical vascular injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2.4. Post-operative antithrombotic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4. Thoracic aorta and thoracic outlet vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1. Blunt thoracic aortic injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1.2. Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.1.3. Grading of thoracic aortic lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.1.4. Management of thoracic aortic injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.1.4.1. Minor aortic injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
4.1.4.2. Pseudoaneurysms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4.1.4.3. Severe aortic injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1.5. Operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1.5.1. Endovascular repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1.5.1.1. Stent graft oversizing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
4.1.5.1.2. Left subclavian artery coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.1.5.2. Open surgical repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4.1.6. Long term follow up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2. Blunt injuries to the aortic arch vessels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.3. Penetrating thoracic aortic injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4.4. Blunt and penetrating subclavian artery injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5. Abdominal vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
5.2. Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.3. Intra-operative management of retroperitoneal haematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.4. Abdominal aorta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.4.1. Non-operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.4.2. Open surgical repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.4.3. Endovascular repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
5.5. Iliac arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.5.1. Open surgical repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.5.2. Endovascular repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.6. Mesenteric arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
5.6.1. Operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.6.2. Non-operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.7. Renal arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.7.1. Non-operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.7.2. Open surgical and endovascular management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
5.8. Inferior vena cava and major abdominal veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.8.1. Inferior vena cava . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.8.1.1. Non-operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.8.1.2. Operative management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
5.8.2. Iliac veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5.8.3. Portal vein and superior mesenteric vein . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
5.8.4. Renal veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
 ESVS 2025 CPGs on the Management of Vascular Trauma 3

6. Extremity vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

6.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6.1.1. Physical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6.1.2. Ankle brachial index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.2. Diagnostic imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.3. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.3.1. Time to repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
6.3.2. Penetrating extremity vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.3.3. Primary amputation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.3.3.1. Decision support tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6.3.4. Non-occlusive extremity vascular injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.3.5. Open or endovascular repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.3.6. Arterial injuries below knee or elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.3.7. Intra-operative heparinisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6.3.8. Extremity venous injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
6.3.9. Compartment syndrome and fasciotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.4. Post-operative surveillance in extremity vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
7. Post-operative general considerations after vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7.1. Post-operative surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7.2. Antibiotic prophylaxis after vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
7.3. Post-operative antithrombotic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
8. Paediatric vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
8.1. General considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
8.2. Neck vessel injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
8.3. Thoracic aortic injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
8.4. Abdominal vascular injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
8.5. Extremity vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
8.6. Post-operative considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
9. Gaps in evidence and recommendations for future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
10. Patients’ perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
10.1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
10.2. Symptoms and diagnosis of vascular trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
10.3. How to stop severe bleeding? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
10.4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
10.5. Follow up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
10.6. Outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

ABBREVIATIONS AND ACRONYMS MESS Mangled Extremity Severity Score

AAST The American Association for the Surgery of MESI Mangled Extremity Syndrome Index
Trauma MRA Magnetic resonance angiography
ABI Ankle brachial index MRI Magnetic resonance imaging
AGREE Appraisal of Guidelines for Research and OSR Open surgical repair
Evaluation PTAI Penetrating thoracic aortic injury
ATLS Advanced Trauma Life Support PV Portal vein
AVF Arteriovenous fistula RCT Randomised controlled trial
AVI Abdominal vascular injury REBOA Resuscitative endovascular balloon occlusion
BCVI Blunt cervical vascular injury of aorta
BTAI Blunt thoracic aortic injury SMA Superior mesenteric artery
CCA Common carotid artery SMV Superior mesenteric vein
CT Computed tomography SVS Society for Vascular Surgery
CTA Computed tomography angiography TBI Traumatic brain injury
DOAC Direct oral anticoagulant TEVAR Thoracic endovascular aortic repair
DSA Digital subtraction angiography
DUS Duplex ultrasound STUDY ACRONYMS
ESVS European Society for Vascular Surgery CADISS Cervical Artery Dissection in Stroke Study
FAST Focused Assessment with Sonography in COMPASS Cardiovascular Outcomes for People Using
Trauma Anticoagulation Strategies
GWC Guideline Writing Committee CRASH-2 Clinical Randomisation of an Antifibrinolytic
ICA Internal carotid artery in Significant Haemorrhage
IVC Inferior vena cava PROOVIT PROspective Observational Vascular Injury
LMWH Low molecular weight heparin Trial

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
4 Carl Magnus Wahlgren et al.

Table 1. Summary table of recommendations.

Recommendations included in the European Society for Vascular Surgery (ESVS) 2025 clinical practice guidelines on the
management of vascular trauma. Numbers correspond to the numbers of the recommendations in the guideline document.
Class I recommendations
1. Rapid access to a 24/7 clinical team competent in haemorrhage control and delivery of both open and endovascular surgery is
recommended for the management of patients with life or limb threatening vascular injuries
2. Implementation of civilian and military vascular trauma curricula and dedicated training are recommended for the development and
maintenance of vascular trauma decision making and technical skills
3. Emergency access to an operating room with hybrid capability is recommended for the operative treatment of the trauma patient with a
vascular injury
4. Damage control resuscitation principles and massive transfusion protocols used for patients with traumatic haemorrhage are
recommended for patients with vascular trauma
5. Early administration of tranexamic acid is recommended for all severely bleeding patients with vascular trauma
6. A pre-hospital tourniquet, applied as distally as possible, is recommended for patients with uncontrolled bleeding from extremity
vascular trauma when local compression and or packing are not sufficient
9. Haemodynamically unstable patients, deemed unsuitable for computed tomography angiography, are recommended to be immediately
transferred to the operating room for surgical intervention
10. Computed tomography angiography, including arterial and venous phase, is recommended as the first line investigation to identify or
rule out vascular injury in trauma patients without clinical signs of active bleeding
12. Restoration of inline arterial flow, temporarily or definitively, is recommended to be prioritised in the management of limb or end
organ threatening vascular trauma
13. Primary definitive repair for patients with vascular trauma is recommended over temporary solutions
14. The use of temporary vascular shunts to rapidly restore blood flow is recommended when timely primary definitive vascular repair is
not feasible due to patient physiology or injury pattern
16. Short interposition grafts are recommended in patients with vascular trauma requiring reconstruction
19. Immediate open surgical exploration is recommended for patients with penetrating neck injury and active haemorrhage from the
wound or expanding haematoma
20. Computed tomography angiography is recommended for all patients with penetrating neck trauma without an indication for immediate
operative intervention
22. Reconstruction rather than ligation of the common or internal carotid artery, when patient physiology allows and technically feasible,
is recommended in patients with a penetrating ESVS Grade 2 or 3 carotid artery injury
25. Emergency endovascular management with embolisation if feasible, is recommended for patients with penetrating extracranial
vertebral artery injury and uncontrolled haemorrhage (ESVS Grade 3)
27. Ligation is recommended if repair of internal jugular vein injury is not easily achievable, provided one internal jugular vein remains
patent
29. Computed tomography angiography including intracerebral vessels is recommended for all patients at risk of blunt cerebrovascular injury
31. Non-operative management with single antiplatelet therapy is recommended for patients with blunt, low grade carotid artery injury
(ESVS Grade 1)
34. Operative treatment with open repair or endovascular stent graft is recommended for patients with blunt carotid artery injury and
active haemorrhage (ESVS Grade 3)
37. Management with antiplatelet therapy as first line treatment is recommended for patients with blunt vertebral artery injury without
active haemorrhage (ESVS Grades 1, 2, or X)
38. Emergency endovascular management with embolisation, if feasible, is recommended for patients with blunt extracranial vertebral
artery injury and uncontrolled haemorrhage (ESVS Grade 3)
40. Systolic blood pressure (90 e 110 mmHg) and heart rate (< 100/minute) control are recommended for patients with untreated blunt
thoracic aortic injury except in the presence of hypovolaemic shock or traumatic brain injury
41. Referral to a trauma centre with 24/7 multispecialty expertise to treat aortic pathology is recommended for all patients with blunt
thoracic aortic injury
43. Computed tomography angiography of the aorta is recommended for the diagnosis and characterisation of blunt thoracic aortic injury
44. Non-operative management with blood pressure control and follow up imaging is recommended in patients with ESVS Grade 1 blunt
thoracic aortic injury without concomitant severe traumatic brain injury
47. Urgent (< 24 hour) endovascular stent graft repair is recommended for patients with blunt thoracic aortic injury and any external
contour abnormality (ESVS Grade 2) with high risk aortic features (see Table 10)
48. Immediate operative repair is recommended for patients with blunt thoracic aortic injury with active extravasation (ESVS Grade 3)
52. Left subclavian artery revascularisation is recommended for selected patients with blunt thoracic aortic injury requiring endovascular
stent graft repair with coverage of the left subclavian artery and risk of compromised perfusion to brain, heart, or spinal cord
54. Open surgical repair is recommended in selected patients with blunt thoracic aortic injury requiring intervention and with aortic
anatomy unsuitable for a stent graft
Continued

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 5

Table 1-continued
55. Active distal aortic perfusion is recommended to minimise the risk of paraplegia for patients with blunt thoracic aortic injury
undergoing open surgical repair
56. Follow up imaging is recommended for patients with blunt thoracic aortic injury who have undergone endovascular stent graft repair,
at one month, one year, and thereafter continued for at least five years
57. Surveillance imaging, until aortic remodelling, is recommended for patients with blunt thoracic aortic injury who have not undergone
thoracic aortic repair
58. Magnetic resonance angiography is recommended as the preferred imaging method for long term surveillance after blunt thoracic
aortic injury
61. Immediate surgical exploration and haemorrhage control are recommended for patients in shock with ongoing bleeding and suspicion
of major abdominal vascular injury
62. Surgical exploration of retroperitoneal haematomas during trauma laparotomy is recommended in patients who are
haemodynamically unstable OR who have an unstable retroperitoneal haematoma (expanding, pulsatile, or actively bleeding)
63. A non-exploratory approach to retroperitoneal haematomas during trauma laparotomy, with subsequent computed tomography
angiography imaging, is recommended for patients who are haemodynamically stable AND have a stable retroperitoneal
haematoma (not expanding, not pulsatile, and not actively bleeding)
64. Non-operative management with surveillance and antithrombotic therapy is recommended for patients without ongoing bleeding and
blunt minor abdominal aortic, iliac, renal, or superior mesenteric artery injuries (ESVS Grade 1) on computed tomography angiography
65. Open surgical repair is recommended as first line treatment for patients with a blunt or penetrating abdominal aortic injury with free
haemorrhage and haemodynamic instability (ESVS Grade 3)
66. Synthetic graft material is recommended for aortic reconstruction in emergency situations with or without concomitant bowel injury
69. Primary surgical repair, synthetic interposition graft reconstruction, or vascular shunting is recommended for common or external iliac
artery injury (ESVS Grade 3) discovered during emergency laparotomy
71. Endovascular treatment with embolisation is recommended for patients with pelvic injury and clinical signs of ongoing bleeding or
imaging showing extravasation from the internal iliac artery or its branches
73. Ligation is recommended for treatment of inferior mesenteric artery injury
76. Ligation of the renal artery, with or without simultaneous nephrectomy, is recommended in a haemodynamically unstable patient with
severe renal artery injury (ESVS Grade 3)
78. Open or endovascular renal artery repair is recommended for patients with bilateral ESVS Grade 2, 3, or X renal artery injuries or if
there is a solitary salvageable kidney
79. Vein ligation is recommended for abdominal venous injury if repair is not easily achievable
82. Careful clinical vascular examination is recommended in all patients with extremity trauma to identify potential haemorrhagic or
ischaemic vascular injuries
84. Immediate computed tomography angiography is recommended as the primary imaging modality in patients with extremity injury
where significant vascular injury cannot be ruled out by clinical vascular examination (palpable peripheral pulses)
85. Revascularisation as soon as possible, ideally within one hour of admission, is recommended in patients with clinical evidence of acute
ischaemia due to extremity vascular trauma
86. The use of a temporary vascular shunt to rapidly restore blood flow in the extremity is recommended when timely primary definitive
vascular repair is not feasible due to patient physiology or skeletal instability
88. Multidisciplinary decision making regarding revascularisation vs. primary amputation is recommended in patients with complex
extremity trauma
91. Endovascular embolisation is recommended for active bleeding from side branches of major arteries in patients with extremity injuries
92. If repair is not easily achievable, ligation is recommended in isolated radial or ulnar arterial injury without evidence of distal ischaemia
96. Emergency four compartment fasciotomy is recommended to treat traumatic post-ischaemic lower limb compartment syndrome
99. Computed tomography angiography is recommended as the first line investigation to identify or rule out vascular injury in
haemodynamically stable paediatric trauma patients
100. Early antithrombotic therapy is recommended for children with blunt, low grade carotid artery injury (ESVS Grade 1 or 2)
102. Immediate surgical exploration and bleeding control are recommended for children in shock with ongoing haemorrhage and suspicion
of major abdominal vascular injury
103. Clinical vascular examination in line with adult guidance is recommended in all children with upper or lower extremity trauma to
identify potential haemorrhagic or ischaemic vascular injuries
Class IIa recommendations
15. Vascular shunts should be considered for conversion to definitive repair as soon as possible, ideally at the primary operation
18. Vein grafts should be considered for vascular reconstruction of arterial injuries requiring longer bypass conduits or for small calibre
distal vessels
24. Endovascular therapy should be considered as first line treatment for symptomatic or progressing pseudoaneurysm or arteriovenous
fistula (ESVS Grade 2) in patients with penetrating vertebral artery injury
Continued

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
6 Carl Magnus Wahlgren et al.

Table 1-continued
26. Non-operative management with single antiplatelet therapy should be considered for patients with penetrating extracranial vertebral
artery injury and occlusion (ESVS Grade X) without neurological symptoms
30. The use of screening protocols to identify cervical vascular injury early should be considered for patients with blunt trauma.
35. Non-operative management with single antiplatelet therapy should be considered for patients with blunt carotid injury and complete
occlusion (ESVS Grade X) without neurological symptoms
36. Management of blunt carotid injury and complete occlusion (ESVS Grade X) with neurological symptoms should be considered on an
individual basis, including the duration of neurological symptoms, risk of reperfusion injury, and signs of brain infarction on computed
tomography.
39. Surveillance with computed tomography angiography at one week and three months should be considered for patients with blunt
carotid artery injury (ESVS Grade 1 or 2) undergoing non-operative management with antiplatelet treatment
46. Delayed (> 24 hour) endovascular stent graft repair should be considered for patients with blunt thoracic aortic injury and any external
wall contour abnormality (ESVS Grade 2) if there are no high risk injury features (see Table 10)
49. Intra-operative systemic heparinisation for thoracic aortic stent graft repair should be considered individualised, including the
perceived risks of bleeding, thromboembolic complications, and severity of traumatic brain injury
50. Stent graft oversizing between 20% and 30%, depending on the hypovolaemic status during index computed tomography angiography,
should be considered for patients with blunt thoracic aortic injury undergoing emergency endovascular treatment
53. Delayed left subclavian artery revascularisation should be considered for selected patients with blunt thoracic aortic injury requiring
endovascular stent graft repair who develop ischaemic symptoms with coverage of the left subclavian artery
59. The treatment choice between open surgical and endovascular repair of innominate artery or proximal left common carotid artery
injury (ESVS Grade 2 and 3) should be considered based on haemodynamic status, anatomy, and concomitant injuries
60. Endovascular stent graft repair should be considered the preferred treatment modality for patients with subclavian artery injury (ESVS
Grade 2 and 3) requiring operative treatment
67. Endovascular stent graft repair should be considered for haemodynamically stable patients and abdominal aortic injury with external
contour abnormality such as a pseudoaneurysm (ESVS Grade 2)
68. Stent graft oversizing between 20% and 30% should be considered when imaging was performed during hypotension for patients with
an abdominal aortic injury undergoing emergency endovascular treatment
70. Endovascular stent graft repair should be considered for ESVS Grade 2 or 3 common or external iliac artery injury
75. Open or endovascular renal artery repair should be considered for haemodynamically stable patients and ESVS Grade 3 renal artery
injury
77. Endovascular stent graft repair should be considered for haemodynamically stable patients with ESVS Grade 2 injury (e.g.,
pseudoaneurysm) of the renal artery
80. Non-operative management with close observation and follow up imaging should be considered in haemodynamically stable patients
with an inferior vena cava injury and a stable retroperitoneal haematoma (not expanding and not actively bleeding)
95. Repair of localised femoral or popliteal venous injury should be considered over ligation in haemodynamically stable patients
101. Endovascular stent graft repair should be considered as the first line operative treatment for children with blunt thoracic aortic injury
(ESVS Grade 2 or 3) and appropriate anatomy
104. Non-operative management should be considered in a child with a pink and warm, but pulseless, hand post-supracondylar humeral
fracture reduction with close observation for the development of acute ischaemia
Class IIb recommendations
17. Synthetic interposition grafts may be considered for emergency definitive vascular repair
21. Non-operative management with single antiplatelet therapy may be considered for patients with minor (ESVS Grade 1) carotid artery
injury due to penetrating trauma
23. Non-operative management with single antiplatelet therapy may be considered for patients with an ESVS Grade 1 vertebral artery
injury due to penetrating trauma
33. Delayed endovascular treatment may be considered for patients with blunt carotid or vertebral artery injury and enlarging
pseudoaneurysm (ESVS Grade 2) or neurological symptoms
45. Endovascular stent graft repair may be considered in patients with ESVS Grade 1 blunt thoracic aortic injury and concomitant severe
traumatic brain injury when blood pressure control is not feasible
72. Endovascular stent or stent graft repair may be considered for ESVS Grade X superior mesenteric artery injury to achieve early
restoration of bowel perfusion
89. Non-operative management with clinical and imaging follow up may be considered for patients with extremity non-occlusive vascular
injuries (ESVS Grade 1 or 2)
90. Endovascular stent or stent graft repair may be considered as an alternative to open repair in selected patients with extremity vascular
trauma requiring operative treatment (ESVS Grade 2, 3, or X)
93. Ligation or embolisation of an isolated infragenicular arterial injury without evidence of distal ischaemia may be considered in patients
with one of the anterior or posterior tibial arteries intact and patent
Continued

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 7

Table 1-continued
94. Intra-operative systemic heparinisation in patients with extremity trauma may be considered on an individual basis, including the
extent of repair, duration of interrupted blood flow, concomitant injuries and overall risk of bleeding, and degree of trauma
induced coagulopathy
97. Post-operative follow up with clinical examination and duplex ultrasound one month after repair, or earlier if abnormal findings or
symptoms develop, may be considered for patients with extremity vascular injury and vascular reconstruction
98. Post-operative single antiplatelet therapy may be considered for patients with vascular trauma who have undergone open or
endovascular repair
105. Post-operative follow up with clinical examination and duplex ultrasound one month after repair, or earlier if abnormal findings or
symptoms develop, may be considered for children with extremity vascular injury reconstructed with bypass or interposition graft
Class IIIa recommendations
7. Heparinisation is not indicated as part of tourniquet management in patients with uncontrolled bleeding from extremity vascular
trauma
51. Routine left subclavian artery revascularisation is not indicated for patients with blunt thoracic aortic injury requiring endovascular
stent graft repair with coverage of the left subclavian artery
81. Atriocaval shunting is not indicated in the management of inferior vena cava injuries
83. An ankle brachial index is not indicated to diagnose or rule out vascular injury in patients with extremity trauma
Class IIIb recommendations
8. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is not recommended as a routine approach for temporary
haemorrhage control in trauma patients with exsanguinating torso haemorrhage
11. Avoiding or postponing computed tomography angiography because of possible renal impairment is not recommended in
haemodynamically stable patients with potentially life or limb threatening vascular injuries
28. Clinical examination alone is not recommended to rule out cervical vascular injury in patients with blunt neck trauma
32. The use of routine endovascular stenting as an adjunct to antithrombotic therapy is not recommended for patients with blunt carotid
artery injury without active bleeding (ESVS Grade 1 or 2)
42. Chest Xray is not recommended as an imaging technique to exclude blunt thoracic aortic injury
74. Revascularisation of a devascularised unilateral kidney identified on computed tomography angiography is not recommended
87. The use of scoring systems when deciding upon limb salvage or amputation for patients with extremity trauma is not recommended
ESVS ¼ European Society for Vascular Surgery.

1. METHODOLOGY primary target audience for these guidelines includes all

clinicians who are directly involved in the management of
1.1. Introduction
vascular trauma, to include vascular and trauma surgeons
Trauma is a major global public health issue, and vascular and trainees in these disciplines, as well as anaesthetists,
trauma sits at the most extreme end of injury care.1 Decisions intensivists, diagnostic and interventional radiologists,
and interventions for massive bleeding make the difference emergency physicians, and plastic and orthopaedic sur-
between life and death, while those for acute ischaemia will geons. The guidelines were therefore developed by a
save limbs and avoid long term disability.The vascular trauma multidisciplinary group of specialists in the trauma field to
field has rapidly evolved over the last decades with improved promote a high standard of care based on the highest
resuscitation strategies, higher quality diagnostic testing, and quality evidence available. The recommendations represent
evolving endovascular techniques.2 A contributing factor to the knowledge at the time of publication, but knowledge in
these changes has been the increased volume of patients this field may change rapidly; therefore, recommendations
with vascular injuries in civilian life and during military con- can become outdated. These guidelines are built on estab-
flicts and terror attacks.3e5 The management of vascular lished principles of Advanced Trauma Life Support (ATLS)
trauma is challenging and time critical. Decisions usually have and damage control resuscitation and surgery.
to be made without the opportunity for planned multi-
specialty discussions. It is therefore critical that clinicians are
supported with clear, practical management approaches 1.2. Guideline Writing Committee
founded on the best available evidence. Members of the Guideline Writing Committee (GWC) were
The European Society for Vascular Surgery (ESVS) has selected by the chairs and ESVS Guideline Steering Com-
therefore developed clinical practice guidelines for the care mittee to represent European and US clinicians involved in
of patients with vascular trauma, with the aim of assisting vascular trauma management, including vascular and trauma
physicians in selecting the optimal management strategy. surgeons, anaesthetists, and interventional radiologists.
The guidelines should under no circumstance be seen as the Members of the GWC have provided disclosure state-
legal standard of care in all patients. The document provides ments regarding relationships that might be perceived as
guidance and support, but the care given to an individual conflicts of interest. These are available from ESVS head-
patient is always dependent on a number of factors. The quarters ([email protected]). Members of the GWC received no
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
8 Carl Magnus Wahlgren et al.

financial support from any pharmaceutical, device, or in-

Table 2. European Society for Vascular Surgery (ESVS)
dustry body to develop these guidelines. There was no clinical practice guidelines levels of evidence grading system.
funding body that influenced the content of these guidelines.
The GWC held introductory meetings when topics and Level of evidence A Data derived from multiple randomised
trials or meta-analyses of randomised trials
author tasks were determined, followed by a face to face Level of evidence B Data derived from a single randomised trial,
meeting in Amsterdam on 25 e 26 May 2023. The GWC high quality* non-randomised studies, or a
drafted a table of contents that was divided into distinct meta-analysis of such studies
sections. Authors were chosen to co-lead the writing of Level of evidence C Data derived from consensus opinion of
each section. Vascular trainees were invited from across experts, from low quality** studies, or meta-
analysis of such studies
Europe to participate in evidence collation and systematic
* Large prospective, population based, observational, or registry
literature reviews.6 The GWC met regularly by videocon- studies.
ference to discuss the writing process and ongoing issues. ** Small retrospective studies or case series.
After the first draft was completed and internally reviewed,
the GWC held a videoconference on 10 May 2024 to review
and approve the wording and grading of each recommen- 1.5. Review process
dation. Consensus recommendations were discussed and
The guideline document underwent a formal external
agreed during these meetings and had to have majority
expert peer review process and, additionally, was reviewed
consensus from all members of the GWC to be included. A
and approved by the ESVS Guideline Steering Committee.
final GWC review and approval of the document were
The guidelines and the app can be downloaded from the
performed following changes made after peer review.
ESVS website (https://www.esvs.org/journal/guidelines/).
The 2025 ESVS clinical practice guidelines on the man-
1.3. Literature search and selection agement of vascular trauma are expected to be updated
A systematic literature search for relevant papers published within a five year period.
in English between 1 January 2000 and 31 December 2022
was performed using the databases MEDLINE (through 1.6. Limitations
PubMed), Embase, Cardiosource Clinical Trials Database,
These guidelines have important limitations affecting gen-
and Cochrane Library. This date range was chosen to ensure
eralisability. There is a general paucity of high quality data
a contemporary view of vascular trauma while ensuring
and literature on vascular trauma management. This applies
sufficient evidence would be included to provide mean-
to aspects relating to sex and ethnicity, but also conditions
ingful recommendations. Literature searches were updated
of low and medium income countries. These limitations
in February 2024. Relevant articles published after the
must be kept in mind when managing vascular trauma in
search dates or in a language other than English were
different settings and environments.
included, but only if they were of paramount importance to
Some topics were deemed to be beyond the scope of
the guidelines. The search terms used for the different
these guidelines, such as iatrogenic vascular injuries,
chapters and subsections are mentioned in Appendix A.
Selection of the literature was performed following the
pyramid of evidence, with aggregated evidence at the top
Table 3. European Society for Vascular Surgery (ESVS)
of the pyramid (systematic reviews, meta-analyses), then clinical practice guidelines class of recommendation
randomised controlled trials (RCTs), then observational grading system.
studies. Single case reports, animal studies, and in vitro
studies at the bottom of the pyramid were excluded. Class Definition Wording
I Evidence and or general agreement that a is or are
1.4. Evidence and recommendation grading criteria given treatment or procedure is recommended
beneficial, useful, effective
The ESVS clinical practice guidelines recommendation II Conflicting evidence and or divergence of
grading system was used for grading the level of evidence opinion about the usefulness or
and class of recommendations.7 For each recommendation effectiveness of the given treatment or
made in the guideline, the level of evidence was graded procedure
IIa Weight of evidence or opinion is in should be
from A to C (Table 2), with A being the highest. The strength favour of usefulness or effectiveness considered
(class) of each recommendation was graded from I to III, IIb Usefulness or effectiveness is less well may be
with class I being the strongest (Table 3). Expanded infor- established by evidence or opinion considered
mation from the studies used for each recommendation is III Evidence or general agreement that a
shown in the tables of evidence (ToE). given treatment or procedure is not
useful or effective, and in some cases may
Appraisal of Guidelines for Research and Evaluation be harmful
(AGREE) II reporting standards for assessing the quality and IIIa The given treatment or procedure is not is or are not
reporting of practice guidelines were adopted during necessarily useful or effective indicated
preparation of the guidelines, and a checklist (AGREE II IIIb The given treatment or procedure may be is or are not
checklist) is available in Appendix A.8 dangerous or harmful to patients recommended

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 9

although many of the described management principles can

Table 4. Orthopaedic injuries associated with vascular
be applied in these situations. There was no formal evalua- injuries.
tion of facilitators and barriers, and the guidelines did not
have the scope to go into detail regarding health economics. Orthopaedic injury Vascular injury
Distal femur fracture Superficial femoral artery
2. VASCULAR TRAUMA GENERAL CONSIDERATIONS Posterior knee dislocation Popliteal artery
Proximal tibia fracture Popliteal artery and trifurcation
2.1. Vascular trauma epidemiology Clavicle fracture Subclavian artery
Vascular trauma is a significant cause of morbidity and Shoulder dislocation Axillary artery
Supracondylar humerus Brachial artery
mortality worldwide.4,9 The epidemiology of vascular fracture
trauma varies depending on the population studied, the Elbow dislocation Brachial artery
mechanism and severity of injury, and the nature of the Cervical spine injury Carotid and or vertebral artery
healthcare environment (e.g., urban, rural, military, or hu- Pelvic fracture Internal iliac artery branches
manitarian situations).1,10e12
Available epidemiological data come mainly from coun-
tries with large population based trauma registries, including tear and subsequent thrombus formation. Examples of or-
the USA, Germany, Sweden, Australia, and the UK.13e16 thopaedic injuries associated with vascular injuries are
Vascular injuries account for approximately 2 e 5% of all provided in Table 4, which also emphasise the importance
trauma admissions.14,17 In the setting of a major European of the clinical vascular examination before and after frac-
trauma centre, vascular injuries were present in 4.4% of total ture reduction. In the thorax, blunt aortic injury can be
trauma admissions.9 The incidence of vascular trauma is caused by deceleration forces leading to shearing in the
highest among young males and is substantially lower in older region of the isthmus, while in the abdomen, lap seat belt
patients (0.7% for patients aged  65 years vs. 2.0% incidence straps may cause direct injury to the aorta.
in younger adults).14 Geriatric patients who sustain a vascular Vascular injury is a leading cause of death and disability in
injury are, however, often more severely injured and are more conflicts.11,20e23 Up to 18% of patients who sustained a battle
likely to have sustained a blunt traumatic vascular injury than related injury had vascular injuries, averaging nearly two
their younger adult counterparts. Vascular trauma in the vascular injuries per patient.21 Extremity trauma dominated,
paediatric population is also less common, occurring in 0.6% followed by torso and cervical injuries.21 In terror related
of all paediatric trauma patients.13 civilian trauma, vascular injury rates can approach 30%,
Penetrating injuries are the most common cause of depending on the type of attack.5,24 Blast injuries, such as those
vascular trauma in urban areas, with a large variation across caused by improvised explosive devices, can lead to complex
or within countries.4,12,17e19 Firearm injuries in particular injury patterns with substantial vascular components.25
carry a highly vascular trauma burden, with up to 16% of
gunshot patients having at least one vascular injury.19 2.2. General principles for vascular trauma care
Firearm injuries requiring vascular repair also have higher Trauma care needs to be organised to ensure that major
injury severity and subsequent mortality rate than injuries trauma patients receive high quality care at the most
with no need for vascular repair.4 Blunt trauma is pre- appropriate hospital across the trauma system. Regional
dominant in rural areas, from mechanisms such as motor trauma centralisation and referral to trauma centres have
vehicle collisions, falls, and industrial accidents. Compared improved trauma care and outcomes, with a reduction in
with penetrating vascular trauma, patients with blunt the mortality rate of severely injured trauma patients.26,27
trauma are in general more severely injured and have These trauma centres have an important role in local
higher mortality and higher limb amputation rates.9 trauma system development, regional disaster planning,
The anatomic distribution of civilian vascular injury in and advancing trauma care through research and use of
large registry data includes the extremities in 44% (upper trauma registries.28 Several trauma systems have been
extremity 26%, lower extremity 18%), followed by the torso described, and the optimal organisation of trauma care
(abdomen 25%, chest 24%), and the neck 10%.2,14 Pene- hospitals may differ between regions and countries.29
trating trauma patients who survive to reach hospital have Established principles of trauma care management to
more extremity and junctional vascular injuries (junction of identify life threatening conditions include the primary
the torso to the extremities, neck, and the perineal region), survey (ABCDE e airway, breathing, circulation, disability,
whilst central vascular injuries are more common following exposure) and secondary survey standardised approach for
blunt trauma.9 rapid initial evaluation of the injured patient.30 There is
From a mechanistic perspective, knife or gunshot wounds literature to support prioritising circulation during the pri-
may cause a direct partial or complete transection of the mary survey in patients with an exsanguinating injury.31 To
vessel. Fractured bone can also directly lacerate vessels. emphasise the importance of rapid bleeding control during
High velocity gunshot wounds can cause indirect damage to the primary patient assessment, an additional initial letter
arteries near the bullet track owing to indirect energy for the mnemonic C-ABCDE, standing for catastrophic hae-
transfer. Blunt trauma may cause vascular injury by morrhage control, has been widely adopted.32,33 Damage
stretching or impingement of the vessel wall with an intimal control principles of resuscitation and surgery apply to the
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
10 Carl Magnus Wahlgren et al.

vascular trauma patient.34,35 Patients who are thought to be specialty. Decision making, exposures, and techniques for
actively bleeding should be taken immediately to the vascular injuries are different from elective and emergency
operating room for emergency exploration.36 Patients who non-trauma vascular surgery. Surgeons must be able to
do not require immediate haemorrhage control will usually rapidly expose and control all major arterial and venous
undergo further diagnostic imaging. structures in the chest, abdomen, pelvis, neck, and upper
and lower limbs. Damage control operative techniques
2.3. Who should perform vascular trauma surgery? include thrombectomy, primary repair, shunting, ligation,
Specific skill sets are required for the effective operative and fasciotomy, and amputation.22 Additional definitive repair
peri-operative management of life or limb threatening procedures include endovascular interventions, vascular
vascular injuries.37 When intervention is required, it has to anastomosis, and graft interposition.
be performed decisively and accurately, often out of working Extremity trauma is the most aligned to other routine
hours. Training and experience in open vascular and endo- emergency and elective vascular procedures, although
vascular procedures varies across Europe and worldwide. there are key differences in decision making, approaches,
While there is a growing consensus that surgeons without and procedures.44 Vascular access and repair for torso
vascular residency or fellowship (or equivalent) should play a trauma may require a multidisciplinary approach including
diminished role in vascular injury management, relatively other specialties (transplant, hepatobiliary, thoracic),
few vascular surgeons have the experience to deliver acute although again there are key differences that must be
vascular trauma care.38,39 Emergency general surgeons have understood.
increasingly limited open vascular training and exposure, Development and maintenance of this skill set in a single
making it difficult to achieve and maintain competence.40e42 surgeon is difficult outside of high volume trauma centres
Despite these challenges, workforce and training solutions with substantial operative workloads. Importantly, surgeons
must be found for all environments.43 must also develop comfort in procedures that start with a
Trauma general surgeons in high volume centres should field full of blood in an actively bleeding and decom-
be capable of managing most penetrating injuries requiring pensating patient. Courses in vascular access and control
open vascular surgery, although infrapopliteal injuries tend using simulation, cadaveric, and animal models can be
to remain the province of vascular surgeons. Emergency valuable in developing and maintaining these skills. Trauma
and general surgeons are much less likely to have endo- surgery involves more complex multiprofessional teams
vascular skills, which may reduce treatment options and than other vascular emergencies and it is critical that sur-
innovation. In paediatric vascular trauma, expertise is much geons understand and are comfortable working within
rarer and combined specialty input is often required. these environments. Interdisciplinary and interprofessional
While vascular trained trauma surgeons do exist in trauma team training, to enhance leadership, teamwork,
pockets across Europe, for most centres a multidisciplinary and communication, is vitally important to ensure suc-
team of general surgery, vascular surgery, and interventional cessful outcomes. Ultimately there may be no substitute for
radiology clinicians will be required to ensure the best, most dedicated time training in a high volume trauma centre,
appropriate interventions can always be delivered. maintained through repeated visits throughout a civilian or
Military environments have a high prevalence of vascular military career.
injuries, and vascular injury is a common cause for forward
surgical intervention. However, there is limited access to Recommendation 2
vascular or endovascular specialists in these environments, Implementation of civilian and military vascular trauma
and deployed personnel may have little recent experience curricula and dedicated training are recommended for the
of these injuries. development and maintenance of vascular trauma decision
making and technical skills.

Recommendation 1 Class Level References

Rapid access to a clinical team 24/7 competent in I C Consensus

haemorrhage control and delivery of both open and
endovascular surgery is recommended for the management
of patients with life or limb threatening vascular injuries.
Class Level References ToE 2.5. When are endovascular therapies required for
I C DuBose et al. (2020), 37
vascular trauma?
Harfouche et al. (2022)39
Endovascular procedures are increasingly used for trauma
care in up to 25% of patients with acute vascular and
associated injuries, although this remains largely for pa-
tients who are haemodynamically stable.38,45
2.4. What technical skill set is required for vascular trauma The most common endovascular procedures are embo-
surgery? lisation of actively bleeding vessels, especially in anatomi-
Effective delivery of vascular trauma surgery requires a cally challenging regions with difficult surgical access
broad skill set not found within a single standard surgical including the pelvis, chest wall, and deep vessels of
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 11

the buttock and extremity, as well as in the management approaches to the administration of the antifibrinolytic
of solid organ injury in haemodynamically stable pa- agent tranexamic acid for patients with vascular injury.61e63
tients.2,46e48 The CRASH-2 trial (Clinical Randomisation of an Anti-
Blunt traumatic aortic injury is where endovascular stent fibrinolytic in Significant Haemorrhage) (n ¼ 20 211 adult
graft repair has clear procedural and outcomes benefits over trauma patients) undertaken in 274 hospitals in 40 coun-
open surgery.46,49 For other vessel injuries, there are multi- tries, randomly assigned patients with, or at risk of, signif-
ple case reports and series in the literature of endovascular icant bleeding to either tranexamic acid (loading dose 1 g
treatments for arterial and some venous injuries.50e52 There over ten minutes then infusion of 1 g over eight hours) or
has been a rise in the use of endovascular techniques for matching placebo.64 All cause death was significantly
trauma management as familiarity, expertise, and availability reduced with tranexamic acid (1 463 [14.5%] tranexamic
have increased. However, these remain less established with acid group vs. 1 613 [16.0%] placebo group; relative risk
a low evidence base. The most effective applications appear 0.91, 95% confidence interval [CI] 0.85 e 0.97). The risk of
to be in areas with challenging open surgical access, such as death due to bleeding was significantly reduced (489 [4.9%]
thoracic aorta and subclavian artery injuries, where endo- vs. 574 [5.7%]; relative risk 0.85, 95% CI 0.76 e 0.96). A
vascular techniques can facilitate a hybrid approach with systematic review including seven RCTs found no compelling
proximal control, or definitive stent graft (covered stent) evidence of increased vascular occlusive events after tra-
repair.2,53,54 Using stent grafts to manage other peripheral nexamic acid administration (odds ratio [OR] 0.96, 95% CI
arterial injuries may not adequately address the local injury 0.73 e 1.27).65 A recent registry (PROspective Observa-
in terms of debridement and concomitant vein or nerve in- tional Vascular Injury Treatment [PROOVIT] registry) study
juries. These approaches may have a role in staged hae- showed that tranexamic acid was not associated with a
morrhage control as part of damage control procedures. higher risk of thrombosis related technical failure in trau-
There are issues of long term patency and durability, in a matic injuries requiring major vascular repairs.66
population that is difficult to follow up. In summary, tranexamic acid should be administered
Emergency hybrid operating rooms suitable for trauma early for all severely bleeding patients with vascular trauma,
care are evolving and experience is growing.55,56 They allow and the dosage should follow standard national and inter-
multimodal approaches to difficult vascular access and national guidelines for the management of trauma patients
haemorrhage control. Hybrid approaches facilitated by based on existing RCT (CRASH-2 trial).64,67,68
these rooms may reduce time to resuscitation and definitive
vascular control when appropriately located and resourced. Recommendation 4
It is likely that the full potential for endovascular or hybrid Damage control resuscitation principles and massive
management of vascular injuries has not yet been realised. transfusion protocols used for patients with traumatic
haemorrhage are recommended for patients with vascular
Recommendation 3 trauma.

Emergency access to an operating room with hybrid Class Level References ToE
capability is recommended for the operative treatment of the I A Holcomb et al. (2015), 58

trauma patient with a vascular injury. Roberts et al. (2011),64

Class Level References Sperry et al. (2018)59

I C Consensus

Recommendation 5
Early administration of tranexamic acid is recommended for
2.6. What approach to resuscitation should be used for all severely bleeding patients with vascular trauma.
vascular trauma?
Class Level References ToE
The management of bleeding trauma patients has been the I A Roberts et al. (2011), 64

subject of intense research, and current guidelines focus on Fouche et al. (2024),65
volume resuscitation with whole blood or equivalent ratios Asaadi et al. (2024)66
of balanced blood components. Modern damage control
resuscitation paradigms for actively bleeding patients target
the prevention, identification, and treatment of coagulop- 2.7. Use of tourniquets for temporary bleeding control
athy and pathophysiological changes associated with severe Most bleeding from extremity vascular injuries can be
ischaemia and massive transfusion.32,57e59 These damage controlled with direct pressure, which remains the imme-
control resuscitation principles integrate permissive hypo- diate mainstay of treatment. However, a small number of
tension, haemostatic resuscitation, and damage control injuries cannot be effectively controlled by local compres-
surgery. No resuscitation research was found that focused sion and or packing, or the nature of the environment
specifically on the management of patients with vascular precludes this. In these circumstances, pre-hospital appli-
injury, as compared with other sources of bleeding.60 In cation of a tourniquet has been shown to improve hae-
particular, no evidence was found to suggest different morrhage control and to reduce transfusion requirements
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
12 Carl Magnus Wahlgren et al.

in both military and civilian settings.69e73 Although no RCTs cardiac arrest.80 Data from observational and non-
have been performed, results from prospective and retro- randomised studies of REBOA are conflicting with a risk of
spective studies are consistent. Pre-hospital application of a bias.79 In a recent RCT, a strategy of in hospital REBOA plus
tourniquet, preferably before the onset of shock, as distal as standard care in the emergency department did not reduce,
possible may prevent exsanguination and save lives, with and may even increase, mortality compared with standard
the risk of reported complications being low.74e76 Tourni- care alone.81 At 90 days, 54% of patients (25/46) in the
quets, with the time of application registered, should be REBOA group had experienced all cause death vs. 42% of
checked frequently to see if they are still required, and patients (18/43) in the standard care group (OR 1.58; [95%
removed as soon as possible under controlled conditions. credible interval, 0.72 e 3.52]; posterior probability of an
Reassessment of the tourniquet for proper placement or OR >1 [indicating increased odds of death with REBOA],
conversion to haemostatic or pressure bandage is especially 86.9%). The incidence of vascular complications of REBOA
important when evacuation is prolonged.77 After tourniquet use has been estimated at 8% (95% CI 5 e 13%).82,83
removal, the patient needs to be assessed for rebleeding as Several factors regarding REBOA, including indications,
well as reperfusion effects with compartment syndrome aortic occlusion time, devices used, training, and creden-
associated with prolonged ischaemia. Heparinisation is not tialling, require further analysis.84,85
indicated specifically because a tourniquet has been used,
and there is no evidence to support this practice. Recommendation 8
Resuscitative endovascular balloon occlusion of the aorta
Recommendation 6 (REBOA) is not recommended as a routine approach for
A pre-hospital tourniquet, applied as distally as possible, is temporary haemorrhage control in trauma patients with
recommended for patients with uncontrolled bleeding from exsanguinating torso haemorrhage.
extremity vascular trauma when local compression and or Class Level References ToE
packing are not sufficient. 81
IIIb B Jansen et al. (2023) ,
Class Level References ToE Maiga et al. (2022)80
I C Scerbo et al. (2017),69
Beekley et al. (2008),70
Covey et al. (2022),71 2.9. What diagnostic imaging should be used for
Benítez et al. (2021),72 emergency diagnosis of vascular trauma?
Henry et al. (2021),74
Teixera et al. (2018)73
Computed tomography angiography (CTA) has sensitivity
and specificity approaching 100% for the identification of
clinically significant vascular injury.86e97 CTA is established
as the first line investigation in haemodynamically stable
Recommendation 7 trauma patients whose outcome would not be impacted by
Heparinisation is not indicated as part of tourniquet the delay associated with this imaging method.95,98 It is also
management in patients with uncontrolled bleeding from the preferred post-operative imaging method to further
extremity vascular trauma. analyse the vasculature when the patient has reached
Class Level References haemodynamic stability. While there are few comparative
IIIa C Consensus studies and some bias, modern CTA, including proper
arterial and venous phases, performs as well as or better
than conventional angiography across all types of vascular
injury.92,95 CTA may be oversensitive in the detection of
2.8. Resuscitative endovascular balloon occlusion of the injuries that are not clinically relevant, and findings must
aorta always be interpreted in line with the clinical status of the
Uncontrolled bleeding from non-compressible torso trauma patient.94,99 While intravenous contrast carries potential
carries a very high mortality rate.78 Resuscitative endovas- risks including contrast nephropathy, overall the risk of
cular balloon occlusion of the aorta (REBOA) is a technique acute kidney injury following intravenous contrast use is
that has been investigated to achieve temporary haemor- very low.100 In patients with potential life or limb threat-
rhage control prior to definitive surgery. REBOA involves ening vascular injuries, it is therefore appropriate to pro-
placement of an endovascular balloon in the aorta to ceed with CTA regardless of the patient’s renal function.
temporarily obtain proximal control of non-compressible Ultrasound investigations have been investigated for the
torso haemorrhage as a bridge to definitive haemorrhage diagnosis of vascular injury. Focused Assessment with So-
control. The use of REBOA should not delay definitive nography in Trauma (FAST) is useful in haemodynamically
haemorrhage control.79 Patient selection identifying which unstable patients to identify free peritoneal, pleural, or
patients may benefit from REBOA remains challenging. A pericardial blood.95,101 The technology is commonly avail-
systematic review identified that variability existed in the able, can be performed and easily repeated during resus-
specific systolic blood pressure trigger used, proactive citation, and does not expose patients or staff to
femoral access, and its use in chest trauma and traumatic radiation.101 While reasonably sensitive and specific for

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 13

clinically relevant haemorrhage, FAST does not identify the

site of torso vascular injury and may miss major retroperi-
toneal vascular trauma.95 In abdominal vascular injury, the
diagnostic sensitivity has been shown to be as low as 41%
when FAST is performed for blunt trauma in the absence of
hypovolaemic shock, and a specificity as low as 18% in
patients with gunshot wounds. Operator dependence may Grade 1
represent a limitation, with a missed injury rate approach-
ing 10%, including major vascular injuries.102,103
Duplex ultrasound (DUS) has been used in the diagnosis
of extremity and neck trauma, but there are few high
quality studies on diagnostic test accuracy.104 Duplex
studies by a trained vascular sonographer are not
commonly available within the required timeframe for the
emergency evaluation of vascular injuries.
Digital subtraction angiography (DSA) has been replaced
Grade 2
by CTA for most diagnostic requirements, as DSA is invasive,
less available, and has a substantially longer acquisition
time in most institutions.105 On table DSA may have a role
as a diagnostic modality in some patients rapidly trans-
ferred to the operating room for the management of other
life threatening injuries. DSA may also complement CTA
where there is doubt about the clinical significance of CTA
findings (artefacts from metallic fragments or bullets, or
below knee or elbow), as part of subsequent therapeutic
intervention (e.g., DSA guided embolisation or proximal
balloon control of arterial injury).

Grade 3
Recommendation 9
Haemodynamically unstable patients, deemed unsuitable for
computed tomography angiography, are recommended to be
immediately transferred to the operating room for surgical
intervention.
Class Level References
I C Consensus

Recommendation 10 Grade X

Computed tomography angiography, including arterial and Figure 1. European Society for Vascular Surgery (ESVS) grading
venous phase, is recommended as the first line investigation system for arterial trauma: Grade 1, injury confined to the intima
to identify or rule out vascular injury in trauma patients or vessel wall with normal external wall contour; Grade 2, external
without clinical signs of active bleeding. wall disruption with contained haemorrhage (e.g., pseudoaneur-
ysm); Grade 3, complete wall transection with free rupture; and
Class Level References ToE Grade X, vessel occlusion.
92
I C Inaba et al. (2006),
Patterson et al. (2012),95 2.10. European Society for Vascular Surgery grading
Walkoff et al. (2021)98 system for arterial trauma
Throughout these guidelines, a new arterial injury grading
system has been used to provide a framework for
Recommendation 11 approaching the management of injuries (Fig. 1). This sys-
tem is based on previous grading systems for individual
Avoiding or postponing computed tomography angiography
because of possible renal impairment is not recommended in arteries (e.g., Society for Vascular Surgery [SVS] thoracic
haemodynamically stable patients with potentially life or aorta injury grades) and modified to reflect contemporary
limb threatening vascular injuries. treatment decisions and pathways.
Class Level References Table 5 shows the overall framework for the ESVS grading
system and a general approach to management indicated by
IIIb C Consensus
each grade.The ESVS Grades are 1 e 3 and X, with Grades 1 e 3
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
14 Carl Magnus Wahlgren et al.

renal artery injury after sudden deceleration. Grade X occlusive

Table 5. European Society for Vascular Surgery (ESVS)
grading system for arterial trauma and management.
injuries may also represent complete transections where
arterial spasm has contained the bleeding and allowed
ESVS Description Examples General thrombus to form, or they may have started as intimal tears
Grade management that have subsequently thrombosed the vessel lumen. Treat-
1 Partial wall Intimal flap Observation  ment of ESVS Grade X injuries is emergency intervention to
injury Intramural antithrombotics restore flow provided the acutely ischaemic limb or end organ
Normal external haematoma (e.g., kidney, brain) is salvageable.
wall contour
2 Complete wall Pseudoaneurysm Urgent repair 2.11. How should perfusion be quickly restored in vascular
injury Arteriovenous trauma?
Abnormal fistula Loss of arterial blood flow to the limb will rapidly result in neural
external wall
and muscular ischaemia resulting in pain, loss of function, ne-
contour
Contained crosis, and amputation.106 Delays to restoration of inline arte-
bleeding rial flow result in unacceptably high rates of vascular trauma
3 Complete wall Blunt arterial Emergency related limb loss. Functional loss begins within two to three
injury transection repair hours of limb injury, and much of this time passes in the pre-
Uncontained Penetrating
hospital and pre-operative phases of care. Also, loss of arte-
haemorrhage arterial injury
X Occlusion Traction injury Emergency rial blood flow in the abdomen or neck may cause end organ
Transection intervention if ischaemia resulting in death or stroke. It is therefore imperative
acutely ischaemic that arterial flow is restored as quickly as possible in the
limb or end organ operating room.107,108 Arterial flow may be restored defini-
is salvageable
tively (primary repair, direct repair, or end to end anastomosis;
graft reconstruction) or temporarily with shunts.109,110 Which
technique is used depends on the injury complexity, time since
representing increasing severity of arterial wall disruption and
injury, and haemodynamic status of the patient.
risk of haemorrhage, and Grade X representing vascular oc-
clusion with distal ischaemia. There are some differences
Recommendation 12
related to individual body regions and arteries, and these are
presented within the text for each section of these guidelines. Restoration of inline arterial flow, temporarily or
definitively, is recommended to be prioritised in the
ESVS Grade 1 injuries are partial injuries to the internal
management of limb or end organ threatening vascular
vessel wall without compromise of the integrity of the trauma.
vessel. This is represented as a normal, smooth external wall
Class Level References ToE
contour on CTA. Examples of such injuries are intimal flaps
or intramural haematomas following blunt or traction in- I C Alarhayem et al. (2019),107
Vuoncino et al. (2023)108
juries. There is no compromise to distal flow or end organ
perfusion. ESVS Grade 1 injuries are usually managed non-
operatively with clinical observation, often supplemented
with surveillance imaging. In some Grade 1 injuries, 2.12. Vascular shunts vs. definitive repair
antithrombotic therapy is indicated, detailed within the The use of temporary vascular shunts is well described as part
relevant sections of these guidelines. of damage control trauma surgery as well as restoring arterial
ESVS Grade 2 injuries have complete disruption of the inflow and, if needed, venous outflow before orthopaedic
vessel wall but there is no external bleeding, or any bleeding fixation or vein harvest for reconstruction.111e113 Shunt use is
is contained. There may be adventitial disruption leading to reported across military and civilian populations, and has been
external bulging of the vessel wall (e.g., in blunt arterial used in paediatric populations.114,115 Shunts should be as
injury) or contained bleeding such as a pseudoaneurysm or short as possible, with a diameter maximised to increase flow
arteriovenous fistula (e.g., after penetrating vascular injury). but not so large that they damage vessel intima. Vascular
ESVS Grade 2 injuries will usually require repair, and endo- shunts can be constructed from a sterile plastic tube, e.g.,
vascular approaches are most commonly applicable. nasogastric tube or small chest drain, provided that the
ESVS Grade 3 injuries have complete disruption of the vessel dimension of the tube reasonably corresponds to the inner
wall with active, uncontained haemorrhage. Bleeding may be diameter of the vessel. Also, commercially available carotid
external or free into the thoracic or abdominal cavity. Patients vascular shunts can be used. There are no strong data to
are in haemorrhagic shock and dependent on volume trans- recommend commercial shunts over improvised shunts.116
fusions. ESVS Grade 3 injuries require emergency repair, and There is no high level evidence to support vascular shunt use,
this will usually be open surgery unless there is rapidly available with most evidence coming from retrospective cohort data,
access to endovascular methods and hybrid operating rooms. most commonly comparing shunting with ligation.109,117,118
ESVS Grade X injuries are occlusive and there is no flow Shunts placed in venous injuries may provide drainage and
beyond the injury. Common examples of these are traction reduce venous hypertension, but short and long term patency
injuries such as popliteal artery injury after knee dislocation or rates are unknown and there is no evidence of improved limb
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 15

outcomes.119,120 The Belfast experience (1979 e 2000) showed

Recommendation 15
that early shunting of both artery and vein in penetrating and
blunt injuries reduced the need for fasciotomy and amputa- Vascular shunts should be considered for conversion to
definitive repair as soon as possible, ideally at the primary
tions compared with the pre-shunt period.121
operation.
Most national trauma and vascular registries do not
capture shunt use. While intuitively they allow faster Class Level References ToE
restoration of flow, this may not be a clinically meaningful IIa C Mathew et al. (2017) 123

time improvement compared with other reconstructive

options. It is of importance to control inflow and backflow
of the injured vessel and to consider distal thrombectomy 2.13. Which technique should be used for vascular graft
before shunt insertion. Shunt complications (e.g., occlusion, reconstruction?
dislodgement, and embolisation) have been reported to When direct primary suture repair is not possible due to the
occur in up to 20% of cases, and placement of a vascular extent of damage to the artery, graft reconstruction is
shunt may alter subsequent repair options.23,122 There is no required. Options for reconstruction are placement of an inline
consensus surrounding the factors associated with shunt interposition graft, or a bypass graft like those employed in
thrombosis, although shunt sizing and vessel calibre have elective vascular surgery. There are no prospective compara-
been implicated.120 Any benefit of routine post-operative tive studies in the literature, follow up is limited without
heparinisation has not been demonstrated. consistent recording of long term patency, and there is wide
Where possible, rapid definitive repair is the preferred heterogeneity in outcome measures.124e128
option. Shunts may be particularly useful where there is Whilst vascular surgeons may be more familiar with bypass
limited vascular expertise to perform reconstruction and procedures, there are several benefits to interposition ap-
where patients have multiple critical injuries that must be proaches. Interposition grafts are substantially shorter and are
dealt with simultaneously. associated with longer patency.124,126 This may be especially
important for younger trauma patients who are less likely to
Recommendation 13 take long term anticoagulant medication and more likely to be
Primary definitive repair for patients with vascular trauma is lost to follow up.128 Interposition approaches also allow for
recommended over temporary solutions. direct inspection of the injury, debridement of devitalised
Class Level References
tissue, and the identification and assessment of concomitant
vein and nerve injuries. In anatomically challenging areas with
I C Consensus
difficult exposure, i.e., thoracic outlet, short interposition
grafts may not be possible. A bypass reconstruction is then a
better option and when extensive soft tissue defect extra-
Recommendation 14 anatomic bypass has been described.129
The use of temporary vascular shunts to rapidly restore blood
flow is recommended when timely primary definitive vascular Recommendation 16
repair is not feasible due to patient physiology or injury pattern. Short interposition grafts are recommended in patients with
Class Level References ToE vascular trauma requiring reconstruction.

I C Tung et al. (2021),111 Class Level References ToE

Borut et al. (2010),112 I C Ray et al. (2019), 124
Subramanian et al. (2008),113 Karmy-Jones et al. (2003),130
Polcz et al. (2021),117 Aksoy et al. (2005),126
Laverty et al. (2022),118 Yagubyan et al. (2004),127
Feliciano et al. (2013)109 Lyons et al. (2024)131

The duration of shunting is not consistently reported in

the literature, and there is little high quality evidence on 2.14. Which graft materials should be used for arterial
timing of removal and definitive repair. Better patency rates reconstruction?
are seen in proximal vessel injuries where there are higher Classically, reversed vein grafts have been recommended for
flows. Experimental and limited human data suggest that vascular reconstruction, although the evidence base for this is
complication rates increase after six hours.123 Few complex historic and based on elective practice in patients with chronic
trauma patients will be taken back within six hours of injury arterial disease requiring long bypasses.11,132e138 There are no
given the time required for critical care stabilisation and RCTs comparing synthetic and autologous grafts in trauma,
scheduling of a definitive procedure. Ideally shunts should with retrospective series subject to substantial biases from
therefore be converted to definitive repair at the primary patient selection, as use of synthetic grafts may be more
procedure. If this is not possible, they should be removed as common in more severely injured patients.11,132,136 In
soon as patient status allows and within 12 hours of complex military vascular trauma with limited non-injured
placement, as a logistically practical timeframe. autogenous venous conduits, emergency use of synthetic

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
16 Carl Magnus Wahlgren et al.

grafts may provide an effective limb salvage strategy.139

Recommendation 18
After stabilisation and transportation to a higher level of
care, elective revascularisation with remaining limited Vein grafts should be considered for vascular reconstruction
of arterial injury requiring longer bypass conduits or for
autologous vein can be performed. Therefore, for patients
small calibre distal vessels.
with vascular injury, substantial tissue loss or contamina-
tion, and limited non-injured autogenous venous conduits, Class Level References ToE
136
synthetic grafts have been suggested as a temporary IIa C Watson et al. (2015),
reconstruction, until the wound is clean, fully debrided, and Forsyth et al. (2024)140
soft tissue coverage can be achieved.136,138
Cohort series report similar early patency rates for 3. NECK VASCULAR TRAUMA
repair of arterial and venous injuries; long term patency
3.1. Penetrating cervical vascular injury
rates are poorly reported.11,132e138,140 A recent large
retrospective databank analysis (n ¼ 8 780) showed that In penetrating neck trauma, vascular injury occurs in up to 20%
vein conduit was associated with less risk of unplanned of cases, depending on mechanism, with the carotid artery
return to the operating room and limb loss compared with being the most injured.147e149 The incidence of penetrating
synthetic grafts.141 However, synthetic bypass use vertebral artery injury in civilian and military populations has
comprised only 1% of upper extremity injuries and 8% of been reported at 3.1% and 0.3%, respectively.150
lower extremity injuries, probably skewing the outcomes 3.1.1. Clinical presentation. Clinical features of penetrating
and may reflect a selection bias. No study has identified cervical vascular injuries are described as hard signs (rapidly
differences in infection rates between synthetic and expanding or pulsatile haematoma, severe haemorrhage or
autologous grafts. Other quoted reasons for using a syn- difficult to control bleeding, shock refractory to resuscita-
thetic graft include long term morbidity from the vein tion, decreased or absent pulse, vascular bruit or thrill, and
harvest site and the pattern of graft failure in the presence neurological deficit) and soft signs (haematemesis, minor
of infection.136 In the setting of infection, veins tend to haemoptysis, dysphonia, dysphagia, and non-expanding
disintegrate leading to haemorrhage, whereas synthetic haematoma).151 Stroke is a feared outcome of cervical
grafts fail at anastomotic lines leading to pseudoaneurysm vascular injuries and may be present initially or emerge
formation.136 during observation or operative treatment.
Overall, there is no high quality evidence to recommend These ESVS guidelines propose a whole neck approach for
autologous or synthetic graft material for repair of trau- the assessment of penetrating neck injuries, rather than the
matic vessel injury. This also applies for conduits when classical three zone description.Wound tracks often cross zone
venous reconstruction is indicated.134,142 Synthetic material boundaries injuring vascular or aerodigestive structures in
appears to be a better conduit for the definitive rapid other zones.152e154 This neck zone classification was devel-
restoration of flow for interposition grafts, while veins may oped prior to widespread CTA availability. Systematic reviews
be more suitable for long bypass conduits or for small comparing management strategies provide evidence to sup-
calibre vessels (such as in paediatric injuries or below the port a more comprehensive assessment of the entire neck,
knee or elbow). There is insufficient evidence to assess the complemented by CTA, improving diagnostic accuracy and
role of other graft materials such as bovine patches or reducing negative surgical exploration rates.149,153,155,156
human acellular matrix grafts.137,143 3.1.2. Diagnostic imaging. A patient with neck trauma who is
When a vein is used, standard teaching is to preferentially actively bleeding and or haemodynamically unstable should
harvest the vein conduit from the uninjured extremity. undergo immediate surgical exploration.157-159 Literature
However, this practice is not supported by high quality data supports that all other patients should have rapid CTA to
and can induce long term morbidity in the uninjured define the injuries and guide management.157,160 Also, for
limb.144 In the absence of evidence to the contrary, it is patients with stroke after neck trauma and haemodynamic
reasonable to harvest the vein from the ipsilateral leg.145,146 stability, immediate CTA is appropriate.158,159,161 Specificity
and negative predictive values of CTA in penetrating cervical
Recommendation 17 vascular injury are 97 e 100%.95 Large vein injury can be missed
Synthetic interposition grafts may be considered for on CTA if not bleeding actively at the time of imaging.95,157
emergency definitive vascular repair.
Class Level References ToE Recommendation 19
132
IIb C Hafez et al. (2001), Immediate open surgical exploration is recommended for
Fox et al. (2005),11 patients with penetrating neck injury and active
Lakhwani et al. (2002),133 haemorrhage from the wound or expanding haematoma.
Parry et al. (2003),134
Class Level References ToE
Stonko et al. (2022),135
Watson et al. (2015),136 I C Bell et al. (2007),157
Reilly et al. (2019),137 Tisherman et al. (2008),158
Ur Rehman (2020)138 Sperry et al. (2013)159

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ESVS 2025 CPGs on the Management of Vascular Trauma 17

Recommendation 20 Table 6. Summary of the general approach to the

management of penetrating cervical carotid or vertebral
Computed tomography angiography is recommended for all
artery injuries. Specific management should follow the
patients with penetrating neck trauma without an indication
recommendations above, individualised to the patient,
for immediate operative intervention.
clinical environment, and available resources.
Class Level References ToE
95 ESVS Description Carotid artery injury Vertebral
I B Patterson et al. (2012),
Grade artery injury
Karagiorgas et al. (2017)162
1 Partial wall Single antiplatelet Single
injury therapy þ surveillance antiplatelet
Normal external therapy þ
3.1.3. Management. A summary of the general approach to wall contour surveillance
2 Complete wall Urgent open surgical Urgent
the management of penetrating cervical carotid or vertebral injury repair or stent graft endovascular
artery injuries is provided in Table 6. Abnormal treatment therapy
3.1.3.1. Penetrating carotid artery injury. ESVS Grade 1 external wall
contour
(intimal tear with preserved external arterial contour).
Contained
Injuries to the carotid intima alone, discovered on CTA, bleeding
are sometimes seen in penetrating neck trauma, more 3 Complete wall Emergency open Emergency
commonly as proximity injuries from gunshot wounds. injury surgical repair endovascular
For injuries with normal external wall contour on CTA, a Uncontained embolisation
haemorrhage or open
non-operative management strategy with antithrombotic
surgical
therapy alone has been reported.163,164 There are no data approach
on specific antithrombotic agents, but the evidence in X Occlusion Individualised Single
general tends to favour the use of a single antiplatelet treatment with common antiplatelet
agent. and or internal carotid therapy
artery reconstruction,
ligation, or
Recommendation 21 antithrombotic or single
Non-operative management with single antiplatelet therapy antiplatelet therapy
may be considered for patients with minor (ESVS Grade 1)
carotid artery injury due to penetrating trauma.
Class Level References ToE Recommendation 22

IIb C Weinberg et al. (2016), 164 Reconstruction rather than ligation of the common or
Ronaldi et al. (2021)163 internal carotid artery, when patient physiology allows and
technically feasible, is recommended in patients with
penetrating ESVS Grade 2 or 3 carotid artery injury.

ESVS Grades 2 e 3 (complete wall injury with contained or Class Level References ToE
uncontrolled haemorrhage). In patients bleeding from ca- I C Plotkin et al. (2023),169
rotid injuries, ligation of the common carotid artery (CCA) or du Toit et al. (2009),167
internal carotid artery (ICA) carries a high probability of Reva et al. (2011),168
Madsen et al. (2024)147
stroke and death. Repair should therefore be performed
whenever possible in patients with surgically accessible ca-
rotid injuries.161,165e168 From North American trauma regis- ESVS Grade X (occlusion). The evidence is lacking, with only
try based data, there was a significantly lower in hospital small case series describing complete occlusion after pene-
mortality rate when reconstruction was performed for ca- trating carotid injury. The treatment approaches with recon-
rotid artery injury (ligation vs. reconstruction: 21% vs. 12% for struction, ligation, or antithrombotic therapy need to be
the CCA and 25% vs. 7% for the ICA, respectively).169 In a individualised considering the timing of injury presentation,
South African study, the procedural mortality rate associated presence and duration of neurological symptoms, injury loca-
with arterial ligation was 45% (9 of 20 patients) and the tion (CCA or ICA), extent of occlusion, risk of reperfusion injury,
mortality rate after arterial repair was 17.6% (23/131).167 and computed tomography (CT) signs of brain infarction.147
Twelve (80%) of 15 surviving patients with a pre-operative 3.1.3.2. Penetrating vertebral artery injury. Clinical presen-
neurological deficit who underwent arterial repair had tation varies from completely asymptomatic to stroke or
improved neurological status. In another retrospective exsanguinating haemorrhage. In two recent systematic literature
analysis, of the nine patients with carotid artery ligation, five reviews (n ¼ 462 and n ¼ 169, respectively), injury to the prox-
developed a neurological deficit; the remaining four patients imal vertebral artery carried the highest mortality rate because
died (100% poor outcomes).168 Of the 37 patients with blood of associated damage to surrounding vital structures.150,170
flow restoration, nine patients died and the neurological ESVS Grade 1 (intimal injury). Non-operative manage-
deficit persisted in two patients (30% poor outcomes). ment with addition of antiplatelet therapy is appropriate for

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
18 Carl Magnus Wahlgren et al.

minimal (ESVS Grade 1) injuries with no neurological ESVS Grade X (occlusion). Non-operative management has
symptoms or active haemorrhage. been suggested for asymptomatic vertebral artery occlu-
sions.184 From registry data from the National Trauma Data
Recommendation 23 Bank, in hospital stroke after penetrating vertebral artery in-
Non-operative management with single antiplatelet therapy
juries in general is relatively uncommon and principally related
may be considered for patients with an ESVS Grade 1 to patient factors and associated injuries.171 Specific data are
vertebral artery injury due to penetrating trauma. lacking on the use of antithrombotic or antiplatelet therapy.171
Class Level References ToE
170
IIb C Piper et al. (2021),
Asensio et al. (2020)150 Recommendation 26
Non-operative management with single antiplatelet therapy
should be considered for patients with penetrating
ESVS Grade 2 (wall disruption and contained haemor- extracranial vertebral artery injury and occlusion (ESVS
rhage). Selective operative management has proved safe. Grade X) without neurological symptoms.
Surgical repair of vertebral arteries is challenging due to diffi- Class Level References
cult access. Therefore, endovascular techniques (coiling,
IIa C Consensus
covered stenting) have become the first line approach for most
cases in the last decades.150,170 Case reports usually describe
technical success with minimal complications, but limited
short or long term outcomes have been reported.171e180 The 3.1.3.3. Penetrating cervical venous injury. An injury to the
first choice procedure for vertebral extracranial haemorrhage, internal jugular vein should be repaired if possible but may
pseudoaneurysm, or arteriovenous fistula (AVF) is endovas- be ligated in a haemodynamically unstable situation.185 If
cular embolisation.181e183 Vertebral artery sacrifice is often there are bilateral internal jugular vein injuries, repair of at
harmless, with few post-operative strokes reported (approxi- least one vein should be attempted.148 The external jugular
mately 4%), provided contralateral or posterior circulation vein can be ligated without consequence.
collateral flow is intact.170 The risk of stroke is higher if em-
bolisation is attempted in the distal vertebral artery segment Recommendation 27
near the posterior inferior cerebellar artery. Asymptomatic
Ligation is recommended if repair of internal jugular vein
AVF can also be managed non-operatively but should be fol- injury is not easily achievable, provided one internal jugular
lowed up to ensure lack of clinical progression. vein remains patent.
Class Level References
Recommendation 24
I C Consensus
Endovascular therapy should be considered as first line
treatment for symptomatic or progressing pseudoaneurysm
or arteriovenous fistula (ESVS Grade 2) in patients with 3.2. Blunt cervical vascular injury
penetrating vertebral artery injury.
Blunt cervical vascular injury (BCVI) has an incidence of 1 e 5%
Class Level References ToE in severely injured patients, with an up to four times higher
IIa C Piper et al. (2021)170 incidence for patients with high impact trauma and associated
Asensio et al. (2020)150 craniomaxillofacial fractures.16,95,186e188
ESVS Grade 3 (uncontrolled haemorrhage). Immediate
3.2.1. Clinical presentation. Blunt injuries are most
endovascular therapy is preferred for severe haemorrhage
commonly asymptomatic on presentation and are detected
(active haemorrhage, hypovolaemic shock, expanding hae-
on CTA. Patients may present with symptoms of stroke due
matoma) due to vertebral artery injury if possible. If not
to carotid occlusion or embolism, but an occlusion may also
possible, a surgical approach with vertebral artery ligation is
be asymptomatic. A more common clinical presentation is
suggested.170,181 Surgical techniques may include arterial
the delayed presentation of stroke due to thromboembolic
ligation, primary repair, transposition of the vertebral artery
complications of an intraluminal injury (ESVS Grade 1 or 2).
to the carotid artery (for proximal injuries), and packing.170
BCVI very rarely presents with the clinical signs associated
with penetrating neck injury and almost never causes active
Recommendation 25 free bleeding and haemorrhagic shock.
Emergency endovascular management with embolisation if
feasible is recommended for patients with penetrating Recommendation 28
extracranial vertebral artery injury and uncontrolled
haemorrhage (ESVS Grade 3). Clinical examination alone is not recommended to rule out
cervical vascular injury in patients with blunt neck trauma.
Class Level References ToE
170 Class Level References
I C Piper et al. (2021),
Asensio et al. (2020)150 IIIb C Consensus

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ESVS 2025 CPGs on the Management of Vascular Trauma 19

3.2.2. Diagnostic imaging. For blunt cerebrovascular injury,

Table 7. Example of screening protocols, the expanded
the diagnostic modality of choice is CTA from the aortic arch Denver screening criteria for blunt cervical vascular injury
and including the extra- and intracranial vessels. Specificity (BCVI). Computed tomography angiography (CTA) is
and negative predictive values of CTA for BCVI have been indicated if at least one criterion is present.186
reported as high as 82 e 100% and 90 e 99%, respec- Signs/symptoms of BCVI
tively.95,189e191
Arterial haemorrhage from neck, nose, or mouth
Cervical bruit in patients aged <50 years
Recommendation 29 Expanding cervical haematoma
Focal neurological deficit
Computed tomography angiography including intracerebral
Neurological examination incongruous with head CT
vessels is recommended for all patients at risk of blunt
findings
cerebrovascular injury.
Stroke on secondary CT scan
Class Level References ToE Risk factors for BCVI (high energy transfer mechanism
I B Patterson et al. (2012), 95 with):
Karagiorgas et al. (2017)162 Le Fort II or III midface fracture
Mandible fracture
Complex skull fracture, basilar skull fracture, or occipital condyle
fracture
The rationale behind screening trauma patients with a
Severe TBI with GCS score <6
neck CTA is to identify patients with BCVI at risk of vascular Cervical spine fracture, subluxation, or ligamentous injury at any
injury causing bleeding, pseudoaneurysm, or thrombosis level
leading to stroke, and who may need medical or operative Near hanging with anoxic brain injury
treatment. Exactly which patients should be screened re- Seat belt abrasion with significant swelling, pain, or altered
mental status
mains unclear. Multiple screening protocols have been
TBI with thoracic injury
proposed, all including both signs and symptoms of BCVI Scalp degloving
and risk factors based on trauma mechanism or associated Thoracic vascular injury
injuries.186,192e197 Too liberal screening leads to over triage, Blunt cardiac rupture
potential over treatment, and unnecessary radiation expo- Upper rib fracture
sure, while too strict protocols lead to missed treatment BCVI ¼ blunt cervical vascular injury; CT ¼ computed tomography;
TBI ¼ traumatic brain injury; GCS ¼ Glasgow Coma Scale.
opportunities.198 No direct prospective comparative or
randomised studies between different screening tools were
identified, but the modified Denver criteria (Table 7) are the Recommendation 31
most extensively studied and widely adopted.186,192,199
Non-operative management with single antiplatelet therapy
Without clear evidence to support the use of one partic-
is recommended for patients with blunt, low grade carotid
ular screening tool, institutions should implement one of artery injury (ESVS Grade 1).
these screening protocols and adjust if required to local
Class Level References ToE
resources and trauma patterns.
201
I C Russo et al. (2021),
Brommeland et al. (2018),192
Murphy et al. (2021),202
Recommendation 30 Shahan et al. (2016),203
The use of screening protocols to identify cervical vascular Momic et al. (2024)204
injury early should be considered for patients with blunt
trauma.
Class Level References ToE ESVS Grade 2 (external wall disruption, pseudoaneurysm).
High grade blunt carotid artery injuries (ESVS Grade 2, e.g.,
IIa C Brommeland et al. (2018),192
Geddes et al. (2016),186
pseudoaneurysm) are less likely to heal compared with low
Biffl et al. (1999),193 grade ones (ESVS Grade 1).205,206 However, the natural history
Biffl et al. (2009),194 of carotid pseudoaneurysms is that the overwhelming ma-
Leichtle et al. (2020),196 jority will heal over time, but the incidence of stroke
Jacobson et al. (2015),195 quadrupled (20% vs. 4.8%) and mortality increased nearly ten
Black et al. (2021)197
fold (36.7% vs. 3.8%) when antithrombotic therapy was
withheld.201 Therefore, antithrombotic treatment has domi-
nated, with endovascular repair reserved for a select few.201
3.2.3. Management The benefit of stenting for more severe blunt carotid
3.2.3.1. Blunt carotid artery injury. ESVS Grade 1 (intimal artery injuries is controversial and limited by stroke as a
tear, dissection, intramural haematoma). For patients with result of in stent thrombosis.201,207 Endovascular treatment
low grade, blunt carotid artery injuries, non-operative (stent graft or stent) has been reserved for pseudoaneur-
management with antithrombotic therapy has support in ysms progressing in size (size threshold of > 10 mm has
the literature.192,200 been suggested) or severe stenosis with thrombotic and or

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20 Carl Magnus Wahlgren et al.

ischaemic symptoms.192,208-210 The selection of patients

Recommendation 35
who will benefit the most from endovascular therapy needs
further evaluation.192,201 Non-operative management with single antiplatelet therapy
should be considered for patients with blunt carotid injury
and complete occlusion (ESVS Grade X) without neurological
Recommendation 32 symptoms.
The use of routine endovascular stenting as an adjunct to Class Level References
antithrombotic therapy is not recommended for patients with
blunt carotid artery injury without active bleeding (ESVS IIa C Consensus
Grade 1 or 2).
Class Level References ToE
201 Recommendation 36
IIIb C Russo et al. (2021),
Weber et al. (2018),16 Management of blunt carotid injury and complete occlusion
Brommeland et al. (2018),192 (ESVS Grade X) with neurological symptoms should be
Kim et al. (2020)210 considered on an individual basis, including the duration of
neurological symptoms, risk of reperfusion injury, and signs
of brain infarction on computed tomography.

Recommendation 33 Class Level References

Delayed endovascular treatment may be considered for IIa C Consensus

patients with blunt carotid or vertebral artery injury and
enlarging pseudoaneurysm (ESVS Grade 2) or neurological
symptoms.
3.2.3.2. Blunt vertebral artery injury. The most common
anatomic location of blunt vertebral artery injury is the mid
Class Level References ToE or distal section of the vessel.214,215 The risk of stroke is
IIb C Lauerman et al. (2015), 209
lower in vertebral than in carotid artery injuries.216
Shahan et al. (2018),208 Treatment modalities for low grade injuries (ESVS Grade
Mei et al. (2014),211
1) have been studied in case series including traumatic,
Burlew et al. (2014),212
DiCocco et al. (2011)213 spontaneous, and iatrogenic causes, and available evidence
is not focused specifically on trauma patients. Non-
ESVS Grade 3 (uncontained bleeding). ESVS Grade 3 in- operative treatment with antithrombotics has been the
juries are rare after BCVI, but continuous bleeding and or first choice. Spontaneous arterial healing during the initial
expanding cervical haematomas should be treated by stent six months post injury is likely.214,217
graft or surgical exploration. For higher grade injuries (ESVS Grade 2), pseudoaneurysms
in general have a benign course, most will not cause symp-
Recommendation 34 toms (< 5% transient ischaemic attack or stroke rate, < 15%
Operative treatment with open repair or endovascular stent recurrence of non-ischaemic symptoms) or enlarge on follow
graft is recommended for patients with blunt carotid artery up (< 15%), and can be managed by antithrombotic ther-
injury and active haemorrhage (ESVS Grade 3). apy.215 Endovascular techniques with embolisation or stent-
Class Level References ing are used for patients with vertebral haemorrhage,
I C Consensus recurrent cerebral ischaemic events despite antithrombotic
therapy, or enlarging pseudoaneurysms.211,215,218,219 If
endovascular therapy is not possible, a surgical approach
ESVS Grade X (occlusion). Occlusive carotid injuries carry with vertebral artery ligation is suggested in patients
a risk of stroke and can be challenging to manage. For pa- with uncontrolled haemorrhage. Non-operative manage-
tients with a complete carotid artery occlusion after blunt ment with antiplatelet therapy seems reasonable for
injury and normal neurological examination, observation asymptomatic blunt vertebral artery occlusions (ESVS
and anticoagulation seem an acceptable approach, but the Grade X).184
evidence is lacking with only small case series described.
Antithrombotic treatment alone has been suggested for Recommendation 37
occlusions of the ICA especially if complete and extending Management with antiplatelet therapy as first line treatment
to the skull base.201 If neurological symptoms are present in is recommended for patients with blunt vertebral artery
the context of carotid artery occlusion, an individualised injury without active haemorrhage (ESVS Grades 1, 2, or X).
approach seems reasonable, taking into account prognostic Class Level References ToE
factors for decision making such as haemodynamics, dura- I B Markus et al. (2019), 220

tion of neurological deficit, and risk of reperfusion injury, Rosati et al. (2020),221
coma, and CT verified brain infarction. The available evi- Patel et al. (2020),214
dence here is very limited to direct management. Daou et al. (2017)222

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ESVS 2025 CPGs on the Management of Vascular Trauma 21

Recommendation 38 Table 8. Summary of the general approach to the

management of blunt carotid or vertebral artery injuries.
Emergency endovascular management with embolisation, if
Specific management should follow the recommendations
feasible, is recommended for patients with blunt extracranial
above, individualised to the patient, clinical environment
vertebral artery injury and uncontrolled haemorrhage (ESVS
and available resources.
Grade 3).
Class Level References ESVS Description Carotid artery Vertebral artery
Grade injury injury
I C Consensus
1 Partial wall Single antiplatelet Single antiplatelet
injury therapy þ therapy þ
Normal surveillance surveillance
3.2.3.3. Antithrombotic therapy. Antithrombotic treatment external wall
for stroke prevention is the mainstay of BCVI treatment and contour
should be started as soon as the diagnosis is made.222e224 2 Complete wall Single antiplatelet Single antiplatelet
Initiating systemic antithrombotic treatment to the multi- injury therapy þ therapy þ
Abnormal surveillance surveillance
ple injured trauma patient needs to be weighed against any external wall Selective Selective
potential bleeding risks such as worsening of intracranial contour endovascular endovascular
haemorrhage or haematomas in solid organs, but there Contained treatment treatment
should be a high threshold for withholding antithrombotic bleeding
treatment for BCVI.188,199,201,203,204,225 3 Complete wall Open surgical or Endovascular
injury endovascular repair embolisation if
A systematic review of asymptomatic BCVI showed that any Uncontained possible, otherwise
choice of antithrombotic therapy was better than no treat- haemorrhage open surgical
ment, but no specific differences between type of antith- approach
rombotic therapy and stroke outcomes were found.202 Other X Occlusion No neurological Single antiplatelet
studies have also reported similar benefits and risks with symptoms: single therapy
antiplatelet therapy
antiplatelets or anticoagulants.201,220,222 However, a recent Neurological
meta-analysis showed that the stroke rate after BCVI was symptoms:
lower for patients treated with antiplatelets than with anti- individualised
coagulants (OR 0.57, 95% CI 0.33 e 0.96). For the studies approach
specifically comparing aspirin with heparin, the stroke rate was
similar between groups (OR 0.43, 95% CI 0.15 e 1.20).204
There was a lower bleeding risk with antiplatelets than with different pharmacological regimens (aspirin; clopidogrel;
anticoagulants (OR 0.29, 95% CI 0.13 e 0.63; p ¼ .002). When dipyridamole; aspirin and clopidogrel; aspirin and dipyr-
specifically evaluating the risk of bleeding complications with idamole; heparin and warfarin; warfarin alone).220,221
aspirin vs. heparin, aspirin showed lower rates of bleeding In summary, there is no higher level of evidence to
complications (OR 0.16, 95% CI 0.04 e 0.58). There is no evi- recommend a specific antithrombotic agent for BCVI
dence of additional benefit of dual compared with single an- treatment, although the evidence tends to favour the use of
tiplatelet treatment.201,222 Some centres initiate treatment a single antiplatelet agent. Antiplatelet therapy seems to
with low molecular weight heparin (LMWH) or systemic hep- have lower rates of bleeding complications in the trauma
arinisation and change early (after 24 e 48 hours) to anti- setting. Given the evidence on the efficacy and safety of low
platelet treatment.192 There is insufficient evidence to make dose aspirin, these guidelines recommend single antiplate-
recommendations for this treatment option.204 Treatment let therapy as the first line antithrombotic regimen for BCVI
should be continued for at least three months or discontinued (Table 8).
earlier if the BCVI has resolved after imaging.192,203e205,220 3.2.3.4. Surveillance of blunt cervical vascular injury. A
There are no data to assess the role of direct oral anticoagu- follow up CTA after approximately seven to ten days of BCVI
lants (DOACs) as alternatives. has been suggested in order to confirm the diagnosis or rule
For cervical vascular dissections, the CADISS (Cervical Ar- out false positive findings (e.g., vessel spasm, low flow, and
tery Dissection in Stroke Study) trial with the inclusion criteria contrast that mimics occlusion).192,200 At this time, around
of extracranial carotid (n ¼ 118) or vertebral (n ¼ 132) artery 50% of low grade injuries (ESVS Grade 1) have resolved
dissections, not entirely traumatic, with neurological symp- while 10% have progressed, leading to changes in man-
tom onset within the last seven days, in combination with agement. Long term, most low grade carotid injuries will
imaging evidence of definite or probable dissection, found no heal.202
significant difference in outcomes between antiplatelet or Early surveillance imaging has been questioned for higher
anticoagulation regimens for three to six months, with annual grade injuries (ESVS Grade 2) as it rarely leads to manage-
recurrent stroke rates of 0.3 e 3.4% and transient ischaemic ment changes, and a three month surveillance image may
attack rates of 0.6 e 1.7%.220 The COMPASS (Cardiovascular be sufficient. It has been suggested that blunt carotid
Outcomes for People Using Anticoagulation Strategies) reg- arterial injuries that resolve spontaneously do so within
istry reported similar outcomes but again not in a specific three to twelve months.226 A three month repeat CTA could
trauma population.221 These two pragmatic studies included guide the continuation or discontinuation of antiplatelet
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22 Carl Magnus Wahlgren et al.

medication.192 It is unclear whether long term follow up is minimise wall shear stress and decrease the potential for
beneficial. In a systematic review, more than 95% of post- expansion or rupture.232,234e239 Administration of intrave-
dissection internal carotid pseudoaneurysms remained un- nous beta blockers with close cardiovascular monitoring is
changed and asymptomatic, but only a few of the included the most used modality for acute blood pressure and heart
cases were considered post-traumatic.227 rate control.240
Outcomes for patients with aortic diseases have been
Recommendation 39 improved with the centralisation of care in high volume
Surveillance with computed tomography angiography at one
trauma centres.Treatment of BTAI requires similar expertise as
week and three months should be considered for patients for other aortic pathologies and should be managed in trauma
with blunt carotid artery injury (ESVS Grade 1 or 2) centres with aortic surgeons offering open and endovascular
undergoing non-operative management with antiplatelet aortic treatment modalities.232,234,235,237,241e243
treatment.
Class Level References Recommendation 40
IIa C Consensus Systolic blood pressure (90 e 110 mmHg) and heart rate
(< 100/minute) control are recommended for patients with
untreated blunt thoracic aortic injury except in the presence
3.2.4. Post-operative antithrombotic therapy. The choice of hypovolaemic shock or traumatic brain injury.
and duration of post-operative antithrombotic therapy after Class Level References ToE
carotid repair varies in the literature and no consensus I C Fabian et al. (1998), 234

agreement yet exists to provide guidance for the need for Neschis et al. (2008),232
anticoagulation and, if so, the type that should be used. For Bossone et al. (2021),235
antithrombotic therapy after stent placement, in an older Gaffey et al. (2020),236
review antiplatelet agents were used (55.8%) most often Osgood et al. (2014),237
Jacob-Brassard et al.
compared with warfarin (17.7%), LMWH (15.9%), and a (2019)238
combination of agents (1.8%).207 In trauma patients, post-
procedural dual antiplatelet treatment may be associated
with an increased risk of bleeding, and each case needs to
be considered individually.192,194,219,228 Post-operative Recommendation 41
antithrombotic combinations have been described for Referral to a trauma centre with 24/7 multispecialty
durations ranging from three months to lifelong expertise to treat aortic pathology is recommended for all
therapy.213,228,229 patients with blunt thoracic aortic injury.
Class Level References ToE
241
I C Ultee et al. (2016),
4. THORACIC AORTA AND THORACIC OUTLET VASCULAR Mohapatra et al. (2021),243
TRAUMA MacKenzie et al. (2006)242

4.1. Blunt thoracic aortic injury

Traumatic blunt thoracic aortic injury (BTAI) is associated 4.1.2. Diagnostic imaging. Chest radiography is a poor
with a high mortality rate with up to 80% of patients screening test and a significant number of aortic injuries will
dying before their arrival at hospital.230e232 The patho- not show any mediastinal abnormalities on plain Xray.244e246
physiology of BTAI relates to the transition from the CTA of the thorax is now the primary diagnostic tool for BTAI
mobile aortic arch to fixed thoracic aorta. The most in all trauma centres. Multislice CTA with 3D reconstruction
common location is the aortic isthmus in 80 e 90% of has been shown to have almost 100% sensitivity and speci-
patients admitted.49 ficity, a 90% positive predictive value, and a 100% negative
predictive value with an overall diagnostic accuracy of
4.1.1. Clinical presentation. The vast majority of BTAIs are
99.7%.247,248 Furthermore, CTA of the aorta with 3D recon-
asymptomatic and are diagnosed on imaging only. For those
struction allows both delineation of the injury severity and
that do rupture, the risk is highest in the first few hours
planning and access for endovascular repair.
after the injury. In an American Association for the Surgery
of Trauma (AAST) multicentre study from the 1990s, 24
Recommendation 42
(8.8%) of the 274 patients in the study population were
admitted to hospital in a stable condition and progressed to Chest Xray is not recommended as an imaging technique to
free rupture in the following 30 hours.231 However, rigorous exclude blunt thoracic aortic injury.
blood pressure control reduces the risk of rupture to about Class Level References ToE
1.5%.233 The systolic blood pressure should be controlled IIIb C Bruckner et al. (2006), 249

usually in the range of 90 e 110 mmHg, depending on the Gutierrez et al. (2016),250
presence of hypovolaemic shock or traumatic brain injury Downing et al. (2001),251
(TBI), and the heart rate < 100 beats per minute to Ho et al. (2002)246

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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ESVS 2025 CPGs on the Management of Vascular Trauma 23

Recommendation 43
Computed tomography angiography of the aorta is
recommended for the diagnosis and characterisation of blunt
thoracic aortic injury.
Class Level References ToE
Grade 1 Grade 2 Grade 3
249
I B Bruckner et al. (2006),
Katayama et al. (2018),252 Figure 2. European Society for Vascular Surgery (ESVS) classifi-
Gutierrez et al. (2016),250 cation of traumatic thoracic aortic injury: ESVS Grade 1, injury
Fabian et al. (1998),234 confined to the intima or vessel wall with normal external wall
Patterson et al. (2012),95 contour; ESVS Grade 2, abnormal external wall contour or external
Ho et al. (2002),246 wall disruption with contained haemorrhage (e.g., pseudoaneur-
Fox et al. (2015),253 ysm); ESVS Grade 3, complete wall transection with free rupture.
Evangelista et al. (2023)254

also be safely managed non-operatively with very low rates

4.1.3. Grading of thoracic aortic lesions. The morphology of of disease progression and aortic related death.237 The
the thoracic aortic lesion on CTA reflects the severity of the largest study to date regarding the natural history of non-
injury and has been integrated into several grading systems, operatively managed BTAI with aortic wall haematoma
the most used of which was adopted by the SVS BTAI demonstrated no evidence of disease progression up to a
guidelines in 2011 and which is consistent with the ESVS five year follow up.236 Recent data from the Aortic Trauma
grading system (Fig. 2; Table 9) (ESVS Grade 1 ¼ SVS Grade Foundation international registry also demonstrated no
I þ II; ESVS Grade 2 ¼ SVS Grade III; ESVS Grade 3 ¼ SVS failures of medical therapy in SVS Grade II patients and no
Grade IV).239,255e258 Among patients with BTAI who present aortic related deaths.240 In a patient cohort with minimal
to the hospital, approximately 40% are ESVS Grade 1, 50% aortic injuries managed medically, the median injury reso-
ESVS Grade 2, and 10% ESVS Grade 3.240 lution time was 39 days for intimal tears and 62 days for
aortic wall haematoma injuries.262 While the existing data
4.1.4. Management of thoracic aortic injury. The optimal suggest that non-operative management of all ESVS Grade 1
time from injury or admission to thoracic aortic repair injuries is safe, further studies with long term CTA follow up
should be individualised according to other severe injuries, are required, ideally in the context of a prospective multi-
the physiological status of the patient, and the grade of centre study.263
aortic injury.
4.1.4.1. Minor aortic injuries (ESVS Grade 1). Minor aortic Recommendation 44
injuries (ESVS Grade 1) are defined as an intimal tear and or Non-operative management with blood pressure control and
intramural haematoma without external contour abnor- follow up imaging is recommended in patients with ESVS
mality. These injuries are supported in the literature to be Grade 1 blunt thoracic aortic injury without concomitant
managed with blood pressure control and observation with severe traumatic brain injury.
regular CTA follow up until resolution of the aortic lesion. A Class Level References ToE
repeat CTA within 48 e 72 hours of admission to assess I C Yadavalli et al. (2023), 264

aortic lesion stability is appropriate. In a small prospective Jacob-Brassard et al.

series of 58 patients, Fabian et al. reported that blood (2019),238
pressure control with beta blockade and sodium nitro- Soong et al. (2019),265
Fox et al. (2015),253
prusside prevented in hospital ruptures, and this is now a
Demetriades et al. (2009),266
standard component of BTAI management.234,259,260 The Alarhayem et al. (2021),267
SVS guidelines suggests that the heart rate should be Harris et al. (2016),258
< 100/minute and the systolic blood pressure around DuBose et al. (2015),260
100 mmHg.239 Hypotension should be avoided in patients Starnes et al. (2012)257
with concomitant major head trauma who require phar-
macological blood pressure support to maintain cerebral
perfusion.240,261 In patients with concomitant major head Recommendation 45
trauma, thoracic endovascular aortic repair (TEVAR) may be
indicated to maintain cerebral perfusion with higher blood Endovascular stent graft repair may be considered in patients
with ESVS Grade 1 blunt thoracic aortic injury and
pressures. There is a lack of treatment evidence for the concomitant severe traumatic brain injury when blood
combination of BTAI and TBI, and decisions on blood pressure control is not feasible.
pressure control or stent graft need to be individualised.
Class Level References ToE
For ESVS Grade 1 aortic injuries with intramural haema- 261
toma, older guidance recommended endovascular repair.239 IIb C Rabin et al. (2014),
Arbabi et al. (2022)268
However, recent studies have shown that these injuries can

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24 Carl Magnus Wahlgren et al.

Table 9. Suggested management approach for blunt thoracic Table 10. High risk features for urgent treatment of blunt
aortic injury (BTAI) based on grade of aortic injury. thoracic aortic injury.257,259,269

ESVS SVS Description Management High risk features

Grade Grade
Large mediastinal haematoma
1 I and Injury confined to the Non-operative: repeat Left haemothorax
II intima or vessel wall CTA within 48 e 72 Aortic coarctation
with normal external hours to assess aortic Large pseudoaneurysm
wall contour lesion stability Systolic blood pressure < 90 mmHg
Major traumatic brain Traumatic brain injury
injury: delayed TEVAR
2 III Abnormal external wall Low risk BTAI features:
contour or external wall delayed (>24 h) TEVAR.
disruption with Stabilisation of other
analysis showed a statistically significantly increased risk of
contained haemorrhage major traumatic injuries
(e.g., pseudoaneurysm) first death in the early repair group (adjusted OR 7.78, 95% CI
High risk BTAI features: 1.69 e 35.70; p ¼ .008). The survival benefits in the delayed
urgent (<24 h) TEVAR repair group were present even for the subgroup without
3 IV Complete wall Emergency TEVAR associated major injuries. Subsequent studies have
transection with free
confirmed that delayed repair is an independent factor
rupture
protective against death.270 The current evidence supports
ESVS ¼ European Society for Vascular Surgery; SVS ¼ Society for
Vascular Surgery; CTA ¼ computed tomography angiography; delayed aortic repair, and that it is not only safe but may be
TEVAR ¼ thoracic endovascular aortic repair; BTAI ¼ blunt thoracic preferable in selected patients, provided there is good
aortic injury. blood pressure control.
An international prospective multicentre registry identi-
fying patients with BTAI (SVS grade I, 3%; grade II, 10%;
4.1.4.2. Pseudoaneurysms (ESVS Grade 2). Thoracic aortic grade III, 78%; grade IV, 9%) with concomitant TBI showed
injury (ESVS Grade 2), defined as having any external wall no difference in delayed cerebral ischaemic events, in
contour abnormality, such as a pseudoaneurysm, should hospital death, or aortic related deaths between patients
undergo TEVAR. There is controversy in clinical practice who had undergone TEVAR at emergency (< 6 hours vs.  6
around the optimal timing of repair. High risk features for hours) or urgent (< 24 hours vs.  24 hours) intervals.268 It
urgent repair have been suggested to include signs of hy- was concluded that the timing of TEVAR did not influence
potension (systolic blood pressure < 90 mmHg), left hae- the outcomes, but as a study limitation patient condition
mothorax, very large mediastinal haematoma, and mass and other requirements could possibly have had an
effect causing aortic coarctation (Table 10).257,259,269 These important influence on the selection of TEVAR timing. The
radiological findings may be indicative of more severe aortic decision to intervene should therefore be guided by indi-
trauma.256,269 vidual patient factors, such as haemodynamic status and
For these ESVS Grade 2 injuries, many studies suggest that the presence of associated injuries rather than the timing of
repair after 24 hours is safe and may benefit patients with TEVAR.268
other injuries. The status of associated organ injuries is crucial
when planning operative management of BTAI.234 Unstable Recommendation 46
pelvic, liver, spleen, other vascular, and abdominal injuries, or Delayed (> 24 hour) endovascular stent graft repair should be
long bone fractures that might need immediate surgical repair, considered for patients with blunt thoracic aortic injury and
could be performed before TEVAR. any external wall contour abnormality (ESVS Grade 2) if
there are no high risk injury features.*
Rabin et al. found that early aortic intervention (< 24
hours) was independently associated with an increased Class Level References ToE
271
aortic morbidity and mortality rate, regardless of repair IIa C Yadavalli et al. (2024),
modality or anticoagulation.261 The results of the AAST Jacob-Brassard et al.
Aortic Injury Study Group suggested that patients treated in (2019),238
Soong et al. (2019),265
a delayed fashion (> 24 hours) after a period of optimisa- Fox et al. (2015),253
tion had improved survival compared with patients with Marcaccio et al. (2018),272
BTAI treated within 24 hours.266 In the AAST multicentre McCurdy et al. (2020),273
prospective study, the mean time from injury to repair was Romijn et al. (2023),274
10.2 hours in the early group and 126.2 hours in the Zambetti et al. (2022),275
Alarhayem et al. (2021),267
delayed group.49 The overall mortality in the delayed repair Demetriades et al. (2009)266
group was statistically significantly lower than the early
* See Table 10.
repair group (5.8% vs. 16.5%; p ¼ .034). Multivariable

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ESVS 2025 CPGs on the Management of Vascular Trauma 25

Endovascular repair is associated with significantly

Recommendation 47
better early outcomes than open repair. In the AAST2
Urgent (< 24 hour) endovascular stent graft repair is study, multivariable analysis showed a significantly lower
recommended for patients with blunt thoracic aortic injury
adjusted mortality rate and fewer blood transfusions in
and any external contour abnormality (ESVS Grade 2) with
high risk aortic features.* the endovascular group compared with the open repair
group. In the subgroup of patients with critical extra-
Class Level References ToE
thoracic injuries, TEVAR was associated with a significant
260
I C DuBose et al. (2015), survival benefit compared with OSR.49 In a meta-analysis
Yadavalli et al. (2024),271
of 699 procedures in which 370 patients were treated by
Jacob-Brassard et al.
(2019),238 endovascular repair and 329 patients were managed by
Soong et al. (2019),265 OSR, the observed mortality rates were 7.6% and 15.2%
Fox et al. (2015),253 (p ¼ .008), respectively. The incidence of procedure
Marcaccio et al. (2018),272 related paraplegia was 5.6% in the OSR group and 0% in
Romijn et al. (2023),274
the endovascular group. The incidence of stroke was
Alarhayem et al. (2021),267
Harris et al. (2015),269 likewise statistically significantly lower in the TEVAR
Starnes et al. (2012)257 group (0.8% vs. 5.3%; p ¼ .003).277
* See Table 10.
Despite improved outcomes with TEVAR compared
with OSR, there are device related complications
including endoleaks, access site vessel complications,
4.1.4.3. Severe aortic injury (ESVS Grade 3). Severe aortic
occlusion of the left subclavian or left common carotid
injuries (ESVS Grade 3) with active extravasation (com-
arteries, and device collapse associated with stent graft
plete transection and free rupture) should be taken for
placement.49,253,278 Intra-operative systemic heparin-
immediate repair.256 Endovascular stent graft repair is
isation needs to be individualised based on the balance
the strongly preferred intervention if resources can be
between the perceived risks of organ bleeding or
mobilised quickly. In settings with limited resources or
severity of TBI and peri-procedural thromboembolic
in young paediatric patients with unsuitable anatomy,
complications.
open surgical repair (OSR) might be the only operative
alternative.
Recommendation 49

Recommendation 48 Intra-operative systemic heparinisation for thoracic aortic

stent graft repair should be considered individualised,
Immediate operative repair is recommended for patients with including the perceived risks of bleeding, thromboembolic
blunt thoracic aortic injury with active extravasation (ESVS complications, and severity of traumatic brain injury.
Grade 3).
Class Level References
Class Level References ToE
IIa C Consensus
I C Yadavalli et al. (2024),271
Jacob-Brassard et al.
(2019),238
Soong et al. (2019),265 4.1.5.1.1. Stent graft oversizing. The presence of an endo-
Fox et al. (2015)253 leak after TEVAR was observed in around 14% of pa-
tients.279,280 The correct size of stent graft is essential in
4.1.5. Operative management of blunt thoracic aortic injury avoiding complications such as type I endoleak or stent
4.1.5.1. Endovascular repair. TEVAR for traumatic thoracic collapse. Routinely, optimal deployment of the stent graft
aortic injuries was first reported in 1997.276 The shift requires oversizing the device by 10 e 20% but increasing
towards endovascular treatment is clearly demonstrated the degree of oversizing up to 30% may be considered in
by two large prospective studies by the AAST in 1997 hypovolaemic patients.279e281 Intravascular ultrasound has
(AAST1) and 2007 (AAST2).40,231 In 1997, all 207 cases limited evidence, and repeat CTA for planning is an alter-
with BTAI were managed by OSR, whereas in 2007, 65% native in patients reaching a normovolaemic state.282,283
of the 193 cases were managed with endovascular stent Excessive oversizing of the stent graft may cause collapse
grafts and only 35% by open repair. In the largest mul- of the device with potentially catastrophic consequences.
ticentre retrospective BTAI examination to date, con- Severe aortic arch angulation can result in poor apposition
ducted by the Aortic Trauma Foundation between 2008 between the stent graft and the thoracic aortic wall,
and 2013, TEVAR was the treatment for 76.4% of the 382 especially at the inner curve.284 Many of these problems
patients with BTAI studied.260 Rates in most established have been addressed with the improvement of stent grafts,
trauma centres now approach 100% for BTAI to the which are now available in curved shapes more suited to
descending aorta. the thoracic aorta of younger patients.

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26 Carl Magnus Wahlgren et al.

Recommendation 50 Recommendation 52
Stent graft oversizing between 20% and 30%, depending on Left subclavian artery revascularisation is recommended for
the hypovolaemic status during index computed tomography selected patients with blunt thoracic aortic injury requiring
angiography, should be considered for patients with blunt endovascular stent graft repair with coverage of the left
thoracic aortic injury undergoing emergency endovascular subclavian artery and risk of compromised perfusion to
treatment. brain, heart, or spinal cord.
Class Level References ToE Class Level References ToE
285
IIa C Jonker et al. (2010), I C Kritayakirana et al.
Muhs et al. (2007),286 (2022),290
Ceja-Rodriguez et al. Chen et al. (2019),291
(2018),283 Sepehripour et al. (2011),292
García Reyes et al. (2018),279 Rizvi et al. (2009),293
Mesar et al. (2022),287 Matsumura et al. (2010),294
Bae and Jeon (2024),281 van der Zee et al. (2019),278
Gennai et al. (2020)288 Romagnoli et al. (2023),295
Kruger et al. (2022),296
McBride et al. (2015)289
4.1.5.1.2. Left subclavian artery coverage. Most studies
recommend coverage of the left subclavian artery if
necessary to obtain a proximal landing zone or to gain
better apposition with the lesser curvature of the aortic Recommendation 53
arch.289 In a database study of 190 patients treated by Delayed left subclavian artery revascularisation should be
TEVAR, DuBose et al. reported occlusion of the left sub- considered for selected patients with blunt thoracic aortic
clavian artery in 41% of cases.260 Although most patients injury requiring endovascular stent graft repair who develop
ischaemic symptoms with coverage of the left subclavian artery.
tolerate subclavian artery occlusion well, a significant
number develop subclavian steal syndrome or arm claudi- Class Level References ToE
cation and require revascularisation with carotide IIa C Kritayakirana et al.
subclavian bypass, re-implantation, or use of endovascular (2022),290
techniques. If the patient has absolute contraindications to Chen et al. (2019),291
Sepehripour et al. (2011),292
left subclavian coverage, such as previous coronary artery
Rizvi et al. (2009),293
bypass graft using the left internal mammary artery or ev- Matsumura et al. (2010),294
idence of dominant left vertebral artery, an urgent carotide van der Zee et al. (2019),278
subclavian bypass should be performed at the time of Romagnoli et al. (2023),295
TEVAR,278,289-296 or by in situ laser fenestration and physi- Kruger et al. (2022),296
McBride et al. (2015)289
cian modified endograft technique.297-299 As yet there are
insufficient data to assess the role of the new thoracic
branched endografts. Patients with an incomplete circle of 4.1.5.2. Open surgical repair. Selected patients with un-
Willis, left upper limb dialysis access, or previous extensive suitable aortic anatomy may continue to require OSR.
aorto-iliac stent graft coverage, compromising the collateral Considerations in selecting OSR include patients anatomi-
supply to the spinal cord, may also require left subclavian cally unfavourable for TEVAR with the absence of an
revascularisation. adequate proximal landing zone to allow for proper seal of
the site of injury by the stent graft. Other anatomical
Recommendation 51 criteria that may preclude TEVAR for BTAI include small
Routine left subclavian artery revascularisation is not (< 7 mm) or diseased iliofemoral vessels, with a risk of ac-
indicated for patients with blunt thoracic aortic injury cess site complications. One of the caveats of OSR in pol-
requiring endovascular stent graft repair with coverage of the ytrauma patients is the need for systemic anticoagulation
left subclavian artery. with the administration of intravenous heparin.
Class Level References ToE In recent years, the use of active distal aortic perfusion to
IIIa C Kritayakirana et al. reduce the risk of paraplegia has become the standard of
(2022),290 care.300,301 In the AAST1 prospective multi-institutional
Chen et al. (2019),291 study, the clamp and sew technique without distal aortic
Sepehripour et al. (2011),292 perfusion was performed in 35% (n ¼ 73) of all patients
Rizvi et al. (2009),293
undergoing OSR.231 In these instances, the paraplegia rate
Matsumura et al. (2010),294
van der Zee et al. (2019),278 was 16.4%. In comparison, in the 134 patients undergoing
Romagnoli et al. (2023),295 OSR using distal aortic perfusion, the paraplegia rate was
Kruger et al. (2022),296 significantly lower at 4.5%. A decade later, a second AAST
McBride et al. (2015)289 multi-institutional prospective study (AAST2), including 193

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ESVS 2025 CPGs on the Management of Vascular Trauma 27

patients subjected to BTAI repair, was published.49 The

Follow up imaging
incidence of the clamp and sew technique without bypass after BTAI
between 1997 and 2007 had decreased from 35% to 16%.
Likewise, the overall incidence of procedure related para-
plegia in patients undergoing OSR had fallen significantly Open surgical Endovascular
No repair
repair repair
from 8.7% to 1.6% (p ¼ .001).
These studies have demonstrated that active distal
perfusion is superior to passive perfusion in reducing the CTA or MRA CTA or MRA MRA
at one year at one month at one month
incidence of procedure related paraplegia. A meta-analysis
of mortality and risk of paraplegia following OSR of trau-
matic aortic rupture in 1 492 patients showed an overall MRA
MRA at one year
Yearly MRA until
MRA continued for
post-operative paraplegia rate of 9.9%.301 Among patients at five years
at least five years
complete remodelling
treated with simple aortic cross clamping, the incidence of
paraplegia was reported as 19.2%. With passive shunting Figure 3. Suggested follow up imaging after blunt thoracic aortic
the incidence of paraplegia was 11.1% and with active injury (BTAI). CTA ¼ computed tomography angiography; MRA ¼
perfusion was 2.3%. magnetic resonance angiography.
In patients who present with free rupture, in settings
with limited resources, the clamp and sew technique might
be the only option. Primary repair is used only in rare needed due to other consequences of implantation of stent
paediatric blunt aortic injuries to avoid coarctation with the grafts (stent graft collapse, hypertension, thrombotic com-
graft as the child grows. plications) in their vasculature at an early age.304-313

Recommendation 54 Recommendation 56
Open surgical repair is recommended in selected patients Follow up imaging is recommended for patients with blunt
with blunt thoracic aortic injury requiring intervention and thoracic aortic injury who have undergone endovascular
with an aortic anatomy unsuitable for a stent graft. stent graft repair, at one month, one year, and thereafter
Class Level References ToE continued for at least five years.

I A Fabian et al. (1997), 231 Class Level References ToE

Demetriades et al. (2008),49 I C Guala et al. (2024), 304
Estrera et al. (2013)302 Khoynezhad et al. (2013),310
Canaud et al. (2015),306
Spiliotopoulos et al.
(2014),311
Recommendation 55 Steuer et al. (2015),312
Gennai et al. (2020),288
Active distal aortic perfusion is recommended to minimise
Makalovski et al. (2018)313
the risk of paraplegia for patients with blunt thoracic aortic
injury undergoing open surgical repair.
Class Level References ToE
I A Fabian et al. (1997),231 Recommendation 57
Demetriades et al. (2008),49 Surveillance imaging until aortic remodelling is
Estrera et al. (2013)302 recommended for patients with blunt thoracic aortic injury
who have not undergone thoracic aortic repair.
4.1.6. Long term follow up. For patients managed non- Class Level References ToE
operatively, the duration of medical therapy and optimal
I C Jacob-Brassard et al.
surveillance regimen remain uncertain. For lesions that (2019),238
persist, routine follow up imaging at one month and twelve Arbabi et al. (2022),240
months and then annually until complete remodelling, is Soong et al. (2019),265
reasonable. Magnetic resonance angiography (MRA) may be Mosquera et al. (2011),314
Madigan et al. (2022)315
a useful alternative to CT, especially in the relatively
younger trauma population who may have a more signifi-
cant risk of malignant disease if lifelong serial CTA studies
are required.303 Finally, there are potential concerns about Recommendation 58
compliance and follow up among trauma survivors. Magnetic resonance angiography is recommended as the
The optimal surveillance protocol after open surgical or preferred imaging method for long term surveillance after
endovascular repair of BTAI remains undefined (Fig. 3). blunt thoracic aortic injury.
Patients are usually enrolled in local TEVAR surveillance Class Level References
programmes with different regularities after the first year
I C Consensus
imaging follow up. Medical follow up of these patients is
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
28 Carl Magnus Wahlgren et al.

4.2. Blunt injuries to the aortic arch vessels (ascending artery is via a median sternotomy and a right cervical or
thoracic aorta and transverse arch, innominate artery, and supraclavicular extension. Proximal control of proximal left
left common carotid artery) sided subclavian injuries is obtained via a median sternotomy.
Rupture of the ascending and transverse aortic arch is un- A separate left supraclavicular incision can be used for distal
common in patients who reach hospital alive, as the mortality control. A hybrid approach combining open and endovascular
rate is high, and exsanguination occurs rapidly. Rupture of the techniques is an alternative for proximal control that may
innominate artery is the second most common thoracic avoid the need for a sternotomy in selected patients.
arterial injury following blunt aortic trauma. Open repair of Endovascular approaches to the repair of subclavian arterial
aortic arch and great vessel injuries requires a median ster- injuries have been described both in blunt and penetrating
notomy. Injuries to the aortic arch may require hypothermic trauma.53,322-325 In appropriately selected patients, stent graft
circulatory arrest and associated antegrade and retrograde placement is associated with improved outcomes for injuries
cerebral perfusion techniques.316 Endovascular solutions in these areas that can be challenging open exposures. Branco
with stent graft for injuries of the innominate artery or left et al. found that endovascular treatment of subclavian injuries
CCA have been described, mostly as case reports in haemo- was associated with lower in hospital mortality and surgical
dynamically stable patients.317,318 Non-operative treatment site infection rates than open repair.53 A report of a large
with antiplatelet therapy for minor injuries to these arteries cohort of patients from the National Trauma Data Bank
(ESVS Grade 1) seems reasonable, but the evidence is lacking. comparing open and endovascular repair found that mortality
was improved with endovascular repair across a wide range of
thoracic vascular injuries.10 Additional literature supports
Recommendation 59
these findings, but with a paucity of long term follow up.326 In
The treatment choice of open surgical or endovascular repair one recent small report (n ¼ 40), primary endovascular stent
of innominate artery or proximal left common carotid artery
injury (ESVS Grade 2 and 3) should be considered based on
graft repair patency was only 42% after five years, but no re-
haemodynamic status, anatomy, and concomitant injuries. interventions were needed because occlusions did not cause
symptoms.327 The PROOVIT registry is capturing data in a
Class Level References
multicentre, multinational fashion to better define the optimal
IIa C Consensus management and follow up of these injuries.2

4.3. Penetrating thoracic aortic injury Recommendation 60

Penetrating thoracic aortic injury (PTAI) is less frequent than Endovascular stent graft repair should be considered the
preferred treatment modality for patients with subclavian artery
BTAI, with only one large retrospective cohort study using the injury (ESVS Grade2 and 3) requiring operative treatment.
National Trauma Data Bank.319 In this series, a total of 2 714
Class Level References ToE
patients with PTAI and 14 037 patients with BTAI were re-
53
ported. Compared with BTAI, patients with PTAI were IIa B Branco et al. (2016),
younger, more often male, and more likely to arrive without Zambetti et al. (2022),328
DuBose et al. (2012),325
signs of life (27.6% vs. 7.5%; p < .001). Patients with PTAI Waller et al. (2017),329
were more likely to have injuries to the oesophagus, dia- Hanif et al. (2023)330
phragm, and heart compared with those with BTAI. Patients
with PTAI were less likely to undergo endovascular repair
(5.8% vs. 30.5%) or OSR (3.0% vs. 4.2%) than patients with 5. ABDOMINAL VASCULAR TRAUMA
BTAI. While the large majority of patients with PTAI died Major abdominal vascular injuries are in general rare, primarily
before arrival or in the emergency department, the in hospital associated with penetrating mechanisms, and carry a high
mortality rate among those who survived the first day was still mortality rate.331e333 The most frequently injured abdominal
43%. In another large registry of 1 186 patients from South vessels are the aorta, superior mesenteric artery (SMA), iliac
Africa, PTAI had a high mortality rate of 30% for patients with arteries, renal arteries, inferior vena cava (IVC), portal vein,
stab wounds and 52% for those with gunshot wounds.320 and iliac veins.13,334,335 These vascular injuries are most often
In unstable patients with PTAI, emergency room thora- combined with other abdominal injuries, liver and bowel in-
cotomy has generated controversy and is best applied to juries in 25 e 35%, and less commonly with splenic, pancre-
patients sustaining penetrating cardiac injuries who arrive atic, and genitourinary injuries (10 e 20%).332,336
at trauma centres with signs of life, pupillary response,
carotid pulse, and cardiac electrical activity with the aim of 5.1. Clinical presentation
alleviating pericardial tamponade, repairing potential car- Abdominal vascular injuries typically present with clinical signs
diac injuries, and providing open cardiac massage.321 of bleeding due to intra-abdominal or retroperitoneal blood
loss. Patients with ongoing haemorrhage require massive
4.4. Blunt and penetrating subclavian artery injury blood transfusion and fast life saving interventions for hae-
Pre-operative CTA for incision planning to obtain proximal morrhage control.331 Patients with major vascular injuries may
control of subclavian artery injuries is valuable. The standard present in cardiopulmonary arrest and require resuscitative
open exposure for proximal injuries to the right subclavian thoracotomy, both of which correlate with poor survival.334,337
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ESVS 2025 CPGs on the Management of Vascular Trauma 29

However, in some cases, patients present with only indirect haematoma not expanding, pulsatile, or actively bleeding
signs with a consequent risk of delayed diagnosis.Thirty percent (stable retroperitoneal haematoma) provide an opportunity
of patients with abdominal arterial injuries are haemody- for further investigation with CTA to direct management. In
namically stable on admission.338 When bleeding has remained patients who are haemodynamically unstable or have an un-
contained by retroperitoneal tamponade, patients with IVC, stable retroperitoneal haematoma (expanding, pulsatile, or
iliac, and other retroperitoneal vascular injuries may present in actively bleeding), surgical exploration of the retroperitoneal
a haemodynamically stable condition.339 The patient’s hae- haematoma during trauma laparotomy is needed. Where
modynamic status determines whether to perform immediate expertise to explore the retroperitoneum is not available,
surgical exploration or to proceed with diagnostic imaging. some haematomas may be temporarily controlled with pack-
ing techniques, to await arrival of expertise or transfer to
5.2. Diagnostic imaging another institution. Where packing does not control substan-
CTA is the primary imaging investigation for abdominal tial arterial injuries, an attempt at exploration and control
vascular injuries and abdominal trauma in general.95,340,341 must be made. Pre-peritoneal packing of unstable intrapelvic
Arterial phase imaging provides optimal visualisation of the haematoma associated with pelvic fracture can be a bridge to
arterial structures and bleeding and, in combination with endovascular control by embolisation.332,345 Where packing
portal venous phase imaging, can help differentiate be- does not stabilise the retroperitoneum, exploration for inter-
tween arterial and venous haemorrhage.342,343 nal iliac artery ligation may be required.

5.3. Intra-operative management of retroperitoneal Recommendation 62

haematoma Surgical exploration of retroperitoneal haematomas during
trauma laparotomy is recommended in patients who are
Patients in shock with ongoing haemorrhage and suspicion haemodynamically unstable OR who have an unstable
of major abdominal injuries should be taken immediately to retroperitoneal haematoma (expanding, pulsatile, or actively
the operating room for exploration, bleeding control, and bleeding).
resuscitation using a major haemorrhage protocol.344 Class Level References
I C Consensus
Recommendation 61
Immediate surgical exploration and haemorrhage control are
recommended for patients in shock with ongoing bleeding
and suspicion of major abdominal vascular injury.
Recommendation 63
Class Level References ToE
A non-exploratory approach of retroperitoneal haematomas
I C Sorrentino et al. (2012)344 during trauma laparotomy, with subsequent computed
tomography angiography imaging, is recommended for
Damage control principles should be used in patients patients who are haemodynamically stable AND have a stable
with active haemorrhage. If there are significant amounts of retroperitoneal haematoma (not expanding, not pulsatile,
and not actively bleeding).
free blood intraperitoneally at trauma laparotomy, resusci-
tative packing should be performed after evacuation of Class Level References
blood and clots, and bowel evisceration. If major haemor- I C Consensus
rhage continues despite peritoneal packing, or the patient
arrests when the abdominal cavity has been opened, the Surgical exploration of the retroperitoneum for traumatic
aorta should be compressed at the hiatus. If cardiac arrest injuries is principally via right or left medial visceral rotation
occurs before the abdominal cavity is entered, an antero- (Fig. 4). Of these, right visceral rotation provides access to
lateral emergency thoracotomy should be performed for
thoracic aortic compression.
The management of retroperitoneal haematomas is low
in evidence but has evolved from trauma experience over
decades and observational studies.345e347 The approach to
retroperitoneal haematomas has traditionally depended on
the haemodynamic status of the patient, mechanism of
injury, location of the retroperitoneal haematoma, and the
presence of associated injuries.332,345 Management of
retroperitoneal haematomas related to the zone classifica-
tion was developed prior to widespread CTA availability and
the increased use of endovascular techniques. Retroperi-
toneal haematomas are not limited by zone boundaries. Right medial visceral rotation Left medial visceral rotation
Patient haemodynamic status and the stability of the
Figure 4. Medial visceral rotations for retroperitoneal exploration
retroperitoneal haematoma will determine the management
and access.
approach. Haemodynamic stability and a retroperitoneal
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30 Carl Magnus Wahlgren et al.

the suprarenal and infrarenal IVC, aorta to the base of the penetrating injuries.348,350 It is also an option after blunt
SMA, all iliac vessels, and the right renal vessels and kidney. occlusive aortic trauma (ESVS Grade X), especially in the
The right rotation can be extended proximally to access the younger population, encountered after CTA investigation. The
retrohepatic and suprahepatic IVC. Left medial visceral opportunities for primary repair are probably limited in most
rotation is reserved for injuries to the coeliac and mesen- cases. The most common reported repair types are recon-
teric portions of the aorta but also the left renal vessels and struction with an aortic tube or bifurcated graft.350 Synthetic
kidney. graft is a reasonable graft material to use in the emergency
Pelvic haematoma exploration, when required, usually situation with or without concomitant bowel injury.
starts over the common iliac artery bifurcation so the origin
of the internal iliac artery can be controlled. Recommendation 65
Open surgical repair is recommended as first line treatment
Recommendation 64 for patients with blunt or penetrating abdominal aortic
Non-operative management with surveillance and injury with free haemorrhage and haemodynamic instability
(ESVS Grade 3).
antithrombotic therapy is recommended for patients without
ongoing bleeding and blunt minor abdominal aortic, iliac, Class Level References ToE
renal, or superior mesenteric artery injuries (ESVS Grade 1) 348
on computed tomography angiography. I C Shalhub et al. (2014),
Charlton-Ouw et al.
Class Level References (2016)350
I C Consensus

Recommendation 66
5.4. Abdominal aorta Synthetic graft material is recommended for aortic
Abdominal aortic injuries are rare, and more severe injury reconstruction in emergency situations with or without
concomitant bowel injury.
grades are associated with a considerable mortality rate.348,349
Class Level References
5.4.1. Non-operative management. Several studies have
I C Consensus
demonstrated high success rates with the non-operative
management (serial imaging for surveillance and blood pres-
sure optimisation) of appropriately selected blunt abdominal 5.4.3. Endovascular repair. Data examining the utility of
aortic injuries. In a Western Trauma Association (WTA) mul- endovascular treatment of abdominal aortic injuries are
ticentre study (113 patients, 0.03% of all blunt trauma pa- very limited. However, extrapolating from more robust data
tients, presenting with blunt abdominal aortic injury at 12 at the thoracic aortic and iliac artery locations, endovascular
major trauma centres), 35.4% of injuries were managed non- techniques may pose benefit to the patient with regard to
operatively with a low failure rate.348 The majority of those the outcome when amenable anatomy is encountered.
selected presented without aortic contour abnormalities In a WTA study (n ¼ 113), 15% of blunt abdominal aortic
(ESVS Grade 1) (89.5% of intimal tears and 44.7% of large injuries underwent endovascular repair.348 A variety of
intimal flaps). In addition, one third of pseudoaneurysms stents and stent grafts were used. All patients in this group
(ESVS Grade 2) were also managed non-operatively. were discharged alive after a median length of stay of 12
In a single centre study from a high volume trauma centre, days. An additional five patients employed endovascular
selective non-operative management was employed in eight therapies as adjuncts to either open or hybrid repair or to
blunt abdominal aortic injuries, with only one subsequent facilitate embolisation of associated injury to abdominal
death attributed to aortic injury.350 Among patients surviving arterial branch injuries.348 Dayama et al. completed a re-
to discharge, no patient had progression of injury on view of the National Trauma Data Bank from 2008 to 2012
outpatient follow up or required additional intervention.350 A for patients sustaining abdominal aortic injury.352 They
similar single centre review from the Shock Trauma Medical found that 28.0% (91/325) underwent endovascular repair
Centre (Baltimore, MD, USA) found that among 17 patients of these injuries. After adjustment for injury characteristics
with blunt abdominal aortic injury, minimal aortic injuries and haemodynamic status, the open repair cohort had 6.6
could be safely observed without major complications.351 In times higher odds of death (95% CI 3.25 e 13.33; p <.001)
that report, all patients underwent repeat imaging during compared with the endovascular repair cohort.
initial hospitalisation and after discharge. No patients sus- As with thoracic aortic endograft sizing, available data
tained malperfusion, death, or progression of injury during suggest that caution should be exercised when making stent
index admission. Only one patient progressed to a pseu- graft size selection based on initial trauma CT scans. Several
doaneurysm eight months after the initial injury.351 studies have shown that volume depletion in trauma pa-
tients may contribute to underestimation of vessel diam-
5.4.2. Open surgical repair. OSR is usually performed when eter and stent graft size needed on these initial scans.283,353
aortic injuries are encountered at the time of initial exploratory A repeat CTA could be valuable for stent graft planning if
laparotomy and is the most common repair type for the patient becomes normovolaemic.

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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ESVS 2025 CPGs on the Management of Vascular Trauma 31

Recommendation 67 Recommendation 69
Endovascular stent graft repair should be considered for Primary surgical repair, synthetic interposition graft
haemodynamically stable patients and abdominal aortic reconstruction, or vascular shunting is recommended for
injury with external contour abnormality such as a common or external iliac artery injury (ESVS Grade 3)
pseudoaneurysm (ESVS Grade 2). discovered during emergency laparotomy.
Class Level References ToE Class Level References
348
IIa C Shalhub et al. (2014), I C Consensus
Dayama et al. (2017)352

5.5.2. Endovascular repair. Endovascular iliac artery injury

(ESVS Grade 2) repair with stent graft, if anatomically
Recommendation 68 suitable, has been reported as a potentially less invasive
Stent graft oversizing between 20% and 30% should be
alternative to open surgery with significantly lower rates
considered when imaging was performed during hypotension of in hospital death, sepsis, and surgical site infec-
for patients with abdominal aortic injury undergoing tion.357,358 Stent graft repair of ESVS Grade 3 injuries can
emergency endovascular treatment. be considered depending on the availability of interven-
Class Level References ToE tional resources, but ESVS Grade X is most commonly
IIa C Jonker et al. (2010),353
treated by open repair. The utility of embolisation of
Ceja-Rodriguez et al. bleeding internal iliac arteries and branches after major
(2018)283 pelvic trauma is well documented.1 Initial management in-
cludes resuscitation, mechanical stabilisation of the pelvis,
and identification and treatment of any extrapelvic bleeding
5.5. Iliac arteries sources. Pelvic angiography and embolisation will benefit
Traumatic iliac vessel injuries, usually caused by a pene- the cohort of patients with clinical signs of bleeding and
trating mechanism, are relatively rare with an incidence of arterial extravasation or indirect signs of bleeding (pseu-
< 2% of all vascular trauma and reported mortality rates of doaneurysm, abrupt cutoff of vessels, AVF, and vascular
24 e 80%.337,354 The high mortality rate of iliac vessel in- spasm) seen on CTA.
juries has frequently been attributed to the absence of
retroperitoneal tamponade, which can lead to fast and Recommendation 70
massive haemorrhage and irreversible shock.339 The com- Endovascular stent graft repair should be considered for ESVS
mon iliac artery is the most frequently injured iliac artery, Grade 2 or 3 common or external iliac artery injury.
with an incidence of 40%, while the internal and external Class Level References ToE
iliac arteries account for 30% each. 357
IIa C Kufner et al. (2015),
5.5.1. Open surgical repair. Ruptured iliac arteries (ESVS Ruffino et al. (2020)358
Grade 3) encountered at damage control laparotomy can
be very challenging given their anatomic location and the
large associated retroperitoneal haematoma.334 Patients
with severe injury and haemodynamic instability may be Recommendation 71
candidates for temporary vascular shunting, which has Endovascular treatment with embolisation is recommended
been found to be safe, with low rates of associated com- for patients with pelvic injury and clinical signs of ongoing
plications and death.355 The common and external iliac bleeding or imaging showing extravasation from the internal
iliac artery or its branches.
arteries should be repaired primarily if possible, and when
there is significant destruction of the vessel wall, recon- Class Level References ToE
struction can be accomplished with a synthetic interposi- I B Velmahos et al. (2000), 359

tion graft. Fu et al. (2012),360

Mortality rates in patients undergoing ligation of the Bonde et al. (2020)361
common or external iliac arteries are documented to be
very high, ranging from 30% to 90%, reflecting the chal-
lenging nature of these injuries as well as the need to 5.6. Mesenteric arteries (superior and inferior mesenteric
restore distal flow as an emergency. Other complications artery, coeliac artery)
include amputation (as high as 54% and 47% for the com- An analysis of the US Trauma Quality Improvement Program
mon and external iliac arteries, respectively).356 One inter- identified 1 403 466 patients where 1 730 had a single
nal iliac artery can be ligated without clinical consequence. visceral artery injury with 699 (40.4%) involving the coeliac
Ligation of both internal iliac arteries can lead to pelvic and artery, 889 (51.4%) the SMA, and 142 (8.2%) the inferior
or ischaemic bowel complications, and ligation of both mesenteric artery.362 There is a paucity of studies on the
vessels is rarely indicated, even in extremis. management strategy.

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
32 Carl Magnus Wahlgren et al.

5.6.1. Operative management. In a damage control situa- from stenting as the warm ischaemia time will always be
tion with injury to the SMA, primary repair is the best op- too long resulting in irreversible renal damage.367,374e376
tion, but if not possible a temporary vascular shunt has
been suggested, although these can be challenging to place Recommendation 74
depending on the level of injury.362,363 There is insufficient Revascularisation of a devascularised unilateral kidney
contemporary literature on the open surgical or endovas- identified on computed tomography angiography is not
cular management of trauma to the mesenteric arteries. recommended.
Operative surgical management (ESVS Grade 2, 3, or X) may Class Level References ToE
consist of primary repair, ligation, interposition graft, extra- 374
IIIb C Ouriel et al. (1987),
anatomic bypass, or the insertion of a temporary vascular Hass et al. (1998),375
shunt.364 If there is suspicion of concomitant pancreatic Jawas et al. (2008)376
injury, the graft can be placed away from the pancreas with
proximal anastomosis from the infrarenal aorta to the
5.7.2. Open surgical and endovascular management.
SMA.364 There are small case series that have demonstrated
Arterial injuries identified peri-operatively can be repaired
the use of stent grafts (ESVS Grade 2, 3, or X).362,363 For the
primarily or reconstructed with a graft.377,378 Overall, the
inferior mesenteric artery, ligation is possible due to the
degree of renal vascular injury and the presence of a normal
mesenteric collateral circulation.
sized uninjured contralateral kidney as well as the physio-
logical status and haemodynamic stability of the patient will
dictate if a nephrectomy is the best option. Renal artery
Recommendation 72
repair has been reported in patients with a solitary kidney
Endovascular stent or stent graft repair may be considered or bilateral injuries in an attempt to avoid permanent renal
for ESVS Grade X superior mesenteric artery injury to achieve
failure.367,379
early restoration of bowel perfusion.
Class Level References ToE
Recommendation 75
362
IIb C Maithel et al. (2020),
Open or endovascular renal artery repair should be
Evans et al. (2021)363
considered for haemodynamically stable patients and ESVS
Grade 3 renal artery injury.
Class Level References
Recommendation 73 IIa C Consensus
Ligation is recommended for treatment of inferior mesenteric
artery injury.
Class Level References
Recommendation 76
I C Consensus
Ligation of the renal artery, with or without simultaneous
nephrectomy, is recommended in a haemodynamically
unstable patient with severe renal artery injury (ESVS Grade 3).
5.6.2. Non-operative management. Non-operative treat-
ment with antithrombotic therapy seems reasonable for Class Level References ToE
379
ESVS Grade 1 injuries, but the evidence is lacking. I C Santucci et al. (2005),
Morey et al. (2021),367
Knudson et al. (2000)377
5.7. Renal arteries
Blunt renal trauma constitutes 90% of all renal trauma Endovascular renal artery stent graft or stent placement
with only 5% involving the renal vasculature.365e367 The in rupture cases (ESVS Grade 3), pseudoaneurysm (ESVS
renal artery is susceptible to injury during rapid decel- Grade 2), or flow limiting dissections (ESVS Grade 1) has
eration owing to the mobility of the kidneys. This may been described, while for the segmental or cortical renal
cause a stretch lesion with subsequent intimal tear or arterial tracts associated with focal bleeding, embolisation
intramural haematoma (ESVS Grade 1), and possibly is suggested as the best option.380
arterial thrombosis (ESVS Grade X).368e371 Studies indi- A summary of the general approach to the treatment of
cate that renal trauma may induce irreversible damage to abdominal arterial injuries is provided in Table 11.
renal vascular integrity, resulting in both short and long
term sequelae such as high blood pressure and kidney Recommendation 77
failure.372,373 Endovascular stent graft repair should be considered for
haemodynamically stable patients with ESVS Grade 2 injury
5.7.1. Non-operative management. Unilateral main arterial (e.g., pseudoaneurysm) of the renal artery.
injuries (ESVS Grade 1) or arterial thrombosis (ESVS Grade
Class Level References ToE
X) are normally managed non-operatively. A devascu-
larised kidney diagnosed on CTA is unlikely to benefit IIa C Liguori et al. (2021)380

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 33

Table 11. Abdominal arterial injuries: summary of general treatment approaches. Specific management should follow the
recommendations above, individualised to the patient, clinical environment, and available resources.

ESVS Description Management

Grade
Common and external Superior mesenteric artery Renal artery
iliac arteries
1 Partial wall injury, Antithrombotic or single Antithrombotic or single Antithrombotic or single
normal external wall antiplatelet therapy þ antiplatelet therapy þ antiplatelet therapy þ
contour surveillance surveillance surveillance
2 Complete wall injury, Consider stent graft Consider stent graft Consider stent graft
abnormal external wall
contour,
pseudoaneurysm
3 Complete wall injury, Open surgical repair, Open surgical repair, shunt or Stable haemodynamics:
uncontained shunt, or stent graft ligate, or stent graft consider operative repair
haemorrhage Unstable haemodynamics: renal
artery ligation

X Occlusion Open surgical repair Non-operative. Endovascular stent Non-operative unless single kidney
(interposition graft) or stent graft repair if inadequate or bilateral renal artery occlusions
Temporarily shunt if collateralisation or salvageable and salvageable kidney. No
required bowel ischaemia revascularisation of a devascularised
unilateral kidney

Recommendation 78 Recommendation 80
Open or endovascular renal artery repair is recommended for Non-operative management with close observation and
patients with bilateral ESVS Grade 2, 3, or X renal artery follow up imaging should be considered in
injuries or if there is a solitary salvageable kidney. haemodynamically stable patients with inferior vena cava
injury and a stable retroperitoneal haematoma (not
Class Level References ToE
expanding and not actively bleeding).
379
I C Santucci et al. (2005),
Class Level References ToE
Knudson et al. (2000)377
386
IIa C Pinto et al. (2023),
Choi et al. (2023)387

Recommendation 79 5.8.1.2. Operative management. Minor IVC injuries can be

Vein ligation is recommended for abdominal venous injury if repaired with simple continuous sutures where some de-
repair is not easily achievable. gree of stenosis is acceptable. Larger defects can tempo-
rarily be controlled with a shunt or can be ligated.
Class Level References ToE
Due to deranged physiology and concomitant injuries, an
I C Balachandran et al. open surgical damage control approach frequently includes
(2020),381
Stonko et al. (2023),52
IVC ligation with an acceptable outcome.52,381e383 In a
Navsaria et al. (2005),382 systematic review, ligation of IVC injuries was associated
Matsumoto et al. (2018),383 with an increased mortality rate compared with repair, but
Howley et al. (2019),335 not in the subset of patients with infrarenal IVC injury.389 In
Asensio et al. (2007),364 a retrospective analysis from the National Trauma Data
Asensio et al. (2003)337
Ksycki et al. (2012),384
Bank, IVC ligation was not independently associated with
Magee et al. (2018)339 death or lower extremity amputation, but it was associated
with acute kidney injury and the need for fasciotomy.390 A
propensity score matching analysis demonstrated that IVC
5.8. Inferior vena cava and major abdominal veins ligation is not superior to repair in decreasing the mortality
5.8.1. Inferior vena cava. IVC injuries are associated with rate in patients with IVC injury.383 However, both these
mortality rates ranging from 30% to 70%, depending on the studies lacked data on anatomic level of injury.383,390 It is
anatomical level, with infrarenal injuries having a better also possible that modern database reports may benefit
outcome.52,381,385 from advances in critical care and use of damage control
5.8.1.1. Non-operative management. A few case reports techniques.389
describe non-operative management of blunt isolated IVC For retrohepatic injuries, packing of the liver onto the
injuries in haemodynamically stable patients with close posterior abdominal wall is the procedure of choice. If
monitoring and observation.386-388 bleeding cannot be controlled with packing, direct

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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34 Carl Magnus Wahlgren et al.

visualisation and repair will be required, although mortality In a study by Howley et al., 24 patients with portal
rates from such injuries are very high. Atriocaval shunting (n ¼ 7) and superior mesenteric (n ¼ 15) vein injuries (two
has been suggested as a modality for these injuries, but patients had combined injuries) were reported with a
evidence supporting its benefit is lacking.391,392 The re- mortality rate of 62% (15/24).335 There were 17 patients
ported literature demonstrates a poor outcome in patients who received direct suture venorrhaphy, including all nine
who required atriocaval shunt, reflecting the high burden of survivors. The study concluded that no firm conclusion
injury and the relative limited use.392 could be drawn regarding techniques for repair. Whether
To reduce surgical morbidity in trauma patients, placement venorrhaphy, ligation, shunting, or bypass is used first,
of a stent graft for the venous injury may represent an alter- salvage techniques are highly unlikely to succeed if the
native to open surgery. In a recent study from the PROOVIT first attempt fails.335 Ligation of the PV and SMV can
database, < 2% of IVC injuries were treated endovascularly cause venous congestion and ischaemia of the midgut
with no increase in overall survival.52 In selected cases of injury and is associated with mortality rates as previously
to the IVC and iliac veins, the use of stent grafts can be suc- described, but ligation is reasonable to perform in a
cessful for urgent bleeding control with good short term re- damage control situation of a haemodynamically
sults. Smeets et al. have reported a series of 35 patients injured compromised patient. Transjugular intrahepatic portosys-
through trauma or with iatrogenic injury during surgery temic shunt (TIPS) is a promising option to treat portal
treated with various stent grafts.393 In all patients, the treat- hypertension at a later stage.398 The inferior mesenteric
ment was technically successful and the 30 day mortality rate vein can be ligated more liberally.
for the entire series was 2.9%, but long term outcome data are
lacking.393 Stent grafts may offer an alternative to IVC injury 5.8.4. Renal veins. Literature of the incidence, morphologies,
management, although their role as a temporary bridge or as management, and outcomes of patients with renal vein in-
definitive treatment needs to be further defined. juries on which to base treatment recommendations is virtu-
ally non-existent. In general, renal vein injuries are repaired by
venorrhaphy and, if this is not possible due to anatomy or
Recommendation 81
physiology, ligation is suggested. Ligation of the left renal vein
Atriocaval shunting is not indicated in the management of near the IVC is usually well tolerated because of venous
inferior vena cava injuries.
collateral outflow. However, this collateral outflow does not
Class Level References ToE exist for the right renal vein, and ligation here usually results in
IIIa C Sullivan et al. (2010), 391
loss of right kidney function.
Zargaran et al. (2020)392

6. EXTREMITY VASCULAR TRAUMA

5.8.2. Iliac veins. Iliac vein injury is often associated with iliac The lower and upper extremities are the most common
artery injury and surgical access may be restricted by the anatomic locations for civilian, military, and terrorism related
overlying artery.337,339 Injuries to the common and external vascular injuries.2,14,21,24 The extremities are particularly sus-
iliac veins can be repaired primarily.384 In a retrospective ceptible to vascular injury both from blunt and penetrating
review, iliac vein ligation was associated with a higher mor- trauma owing to the relatively unprotected anatomic position
tality rate than repair (OR 2.2, 95% CI 1.08 e 4.66), but no of the vasculature, proximity to the long bones, and suscep-
statistically significant difference in deep venous thrombosis, tibility of the elbow and knee joints to fracture or dislocation.
pulmonary embolism, fasciotomy, or amputation.339 These In many patients there is concomitant injury to the nerves.This
data supported that repair of iliac vein injuries was preferable may hinder diagnosis of the vascular injury and is of foremost
to ligation whenever feasible. Ligation of the iliac veins is importance for long term functional outcomes. The risk of
suggested in the literature for complex venous injuries or amputation after extremity vascular trauma is substantial, and
haemodynamically unstable patients.337,384 Previous studies long term results are often disappointing with many patients
have shown that ligation of the common or external iliac vein experiencing chronic pain, motor and sensory deficits, and
is tolerated with few adverse sequelae and similar rates of difficulties with activities of daily living.141,399,400 Limb salvage
complications compared with repair.337,384 There are no data and good functional outcome rates are closely related to time
supporting venous reconstruction using interposition grafts to revascularisation, and restoration of arterial flow must be
in the multiple trauma patient. prioritised in managing extremity vascular injuries.

5.8.3. Portal vein and superior mesenteric vein. Although

uncommon, injuries to the portal vein (PV) and superior 6.1. Clinical presentation
mesenteric vein (SMV) are associated with mortality rates 6.1.1. Physical examination. Careful physical examination
between 40% and 72%.334,364,394e397 As the PV and SMV are guides diagnostic investigations and treatment decisions.
located at the root of the mesentery, concomitant injuries to In extremity vascular trauma, active haemorrhage
the IVC, pancreas, liver, and or gastrointestinal tract are clas- (external bleeding, expanding haematoma) or absent
sically encountered and will influence treatment options. In- palpable pulse are indicators of clinically significant dam-
juries can be repaired with continuous sutures or controlled age to a vascular structure (ESVS Grade 3 or X).93,400e402
temporarily by inserting a shunt. However, the absence of these signs does not exclude
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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ESVS 2025 CPGs on the Management of Vascular Trauma 35

vascular injury. Clinical examination of the injured and any vascular trauma has not been investigated extensively.
non-injured extremity is essential to specifically evaluate However, in cases where pseudoaneurysms or arteriove-
the limb for any haemorrhagic or ischaemic signs, e.g., nous fistulae are suspected, DUS may have a potential role
absence of easily palpable peripheral pulses, delayed to play.
capillary refill, pallor, paraesthesia, pain, or paralysis.96
Importantly, accompanying nerve injury, which is particu- Recommendation 84
larly prevalent in elbow or knee dislocations, may hinder Immediate computed tomography angiography is
evaluation of the vascular status. The presence of an easily recommended as the primary imaging modality in patients
palpable peripheral pulse in both the upper and lower with extremity injury where significant vascular injury
extremities is crucial, as it can rule out significant vascular cannot be ruled out by clinical vascular examination
injuries, as shown in several large retrospective (palpable peripheral pulses).
studies.93,400e402 Conversely, if peripheral pulses are not Class Level References ToE
easily palpable, prompt imaging must be performed to rule I C Adibi et al. (2014), 86

out arterial injury. Branco et al. (2015),89

Jens et al. (2013)94
Recommendation 82
Careful clinical vascular examination is recommended in all 6.3. Management
patients with extremity trauma to identify potential
haemorrhagic or ischaemic vascular injuries. 6.3.1. Time to repair. In patients with limb ischaemia sec-
Class Level References ToE ondary to major arterial injury (ESVS Grade X), the classic
teaching has been that limb salvage is possible up to six hours
I C Abou-Sayed et al. (2002),400
Inaba et al. (2011),93
from onset (which approximates to the time of injury). This is
Joseph et al. (2021),401 largely based on clinical experience in the management of
Le Roux et al. (2021)402 acute limb ischaemia secondary to thromboembolic disease or
atherosclerosis. Applying this time threshold to extremity
6.1.2. Ankle brachial index. Several studies have explored vascular trauma in a meta-analysis of over 3 000 patients un-
the usefulness of the ankle brachial index (ABI) and have dergoing revascularisation demonstrated that duration of
reported conflicting results regarding its ability to rule out ischaemia exceeding six hours was an independent prognostic
significant arterial injuries in both blunt and penetrating factor for amputation.408 However, in a recent US national
trauma.403e406 Its added value compared with a thorough registry study of nearly 4 500 patients with extremity vascular
physical examination conducted by an experienced physi- trauma, the amputation rate was significantly lower in those
cian is limited.93,400e402 Moreover, obtaining an accurate who had a time within 60 minutes from injury to arrival in the
ABI requires time and skill. operating room for revascularisation (33/554) compared with
those who arrived after one to three hours (255/2 186) and
three to six hours (171/1 275) (6.0% vs. 11.7% and 13.4%,
Recommendation 83 respectively).107 Time to revascularisation remained a signifi-
cant predictor of limb salvage in multivariable analysis adjust-
An ankle brachial index is not indicated to diagnose or rule
out vascular injury in patients with extremity trauma. ing for injury severity, mechanism of injury, and age. Similarly,
data from a US/UK military dataset found a linear relationship
Class Level References ToE
between ischaemic time and successful limb salvage with a
IIIa C Abou-Sayed et al. (2002),400 10% reduction in the probability of successful limb salvage for
Inaba et al. (2011),93
every hour delay from injury to revascularisation.409 The
Joseph et al. (2021),401
Le Roux et al. (2021)402 probability of limb salvage was 86% when ischaemia time was
within one hour. The presence of shock more than doubled the
risk of failed limb salvage. There is similar evidence in upper
6.2. Diagnostic imaging limb vascular injuries with data from over 5 000 arterial repairs
CTA should be performed in all patients with suspected finding a significant decrease in the rate of amputation when
vascular trauma to the extremities, following a careful patients underwent revascularisation within 90 minutes of
physical examination. CTA has high sensitivity and speci- injury.410 In summary, there is no safe window in which to
ficity for detecting arterial injury.94 It is important to note revascularise a patient with a traumatised and ischaemic limb.
that imaging should be conducted promptly without These patients need to be prioritised within the hospital sys-
causing any delay in treatment. In certain urgent cases, tem. A management strategy with pre-operative CTA to
immediate treatment should be administered without prior delineate the extremity vascular injury, while preparing an
imaging.407 operating room, could be valuable in selected patients and may
If pre-operative imaging is not feasible, intra-operative not cause a treatment delay in most hospital systems
angiography can be a beneficial diagnostic and to decide nowadays.96
an open or endovascular approach. The role of magnetic To reduce the risk of limb loss or ischaemic complications,
resonance imaging (MRI) and DUS in assessing extremity restoration of in line arterial flow is considered an immediate
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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36 Carl Magnus Wahlgren et al.

priority, with the best outcomes observed in those patients with shunting, primary repair, end to end anastomosis, or
with the shortest overall ischaemic times. Arterial flow should interposition grafts depending on the individual circum-
be restored, temporarily or definitively, prior to skeletal stabi- stances. Early surgical intervention is crucial for minimising
lisation, fasciotomy, and or other procedures. Compartment ischaemic damage and improving long term outcomes.
syndrome is principally a reperfusion injury and fasciotomy
should not be the primary procedure for ischaemic extremity 6.3.3. Primary amputation
vascular injury. A more detailed discussion with recommen- 6.3.3.1. Decision support tools. The decision to proceed to
dations regarding the use of shunts is available in Sections 2.11. revascularisation or amputation in complex extremity vascular
and 2.12. trauma can be extremely difficult. The morphology of injury is
not the only consideration when deciding to pursue limb
revascularisation. Patient and limb factors, mechanism of injury,
Recommendation 85
and even local environmental factors should all be evaluated to
Revascularisation as soon as possible, ideally within one determine treatment. Several objective scoring systems have
hour of admission, is recommended in patients with clinical
evidence of acute ischaemia due to extremity vascular
been developed to aid the clinician in complex decision making.
trauma. The Mangled Extremity Severity Score (MESS) and Mangled
Extremity Syndrome Index (MESI) are two of the more recog-
Class Level References ToE
nised but were formulated using retrospective data.416,417
I C Alarhayem et al. (2019),107 Upper limb. A large systematic review of 6 113 upper limb
Perkins et al. (2022),409
Glass et al. (2009),411
trauma cases showed that the MESS alone does not accu-
Perkins et al. (2015),408 rately predict the need for amputation.418 This finding has
Ray et al. (2019),124 been supported by another systematic review of upper limb
Zaraca et al. (2011),412 scoring systems.419 The MESI may be more precise but was
Hsieh et al. (2022),413 based on a single retrospective study. Other small case
Chipman et al. (2023),410
Lewis Jr et al. (2022),414
series have not shown high levels of evidence to support
Magnotti et al. (2020)415 using scoring systems alone to guide management.420e424
Lower limb. A systematic review of 17 studies of lower ex-
tremity injury revealed that MESS was the most frequently
used scoring system.425 Overall, scoring systems were not
Recommendation 86 useful in predicting functional limb salvage, or useful alone in
The use of a temporary vascular shunt to rapidly restore predicting whether to amputate or reconstruct. Another small
blood flow in the extremity is recommended when timely retrospective study supports the finding that MESS does not
primary definitive vascular repair is not feasible due to predict delayed amputation in patients with isolated popliteal
patient physiology or skeletal instability.
arterial injuries.426
Class Level References ToE Secondary amputation. Perkins et al. performed a meta-
I C Tung et al. (2021), 111 analysis of 3 187 lower extremity vascular reconstructions.
Borut et al. (2010),112 Factors associated with a substantial increase in amputation
Subramanian et al. included soft tissue injury, presence of compartment syn-
(2008),113
drome, levels of arterial injury, duration of injury, and associ-
Polcz et al. (2021),117
Laverty et al. (2022),118 ated fractures.427
Feliciano et al. (2013)109 In summary, no contemporary scoring system on its own
should be used to decide whether to salvage or amputate an
6.3.2. Penetrating extremity vascular trauma. Whilst blunt injured extremity. A multidisciplinary, senior team based de-
trauma may result in more Grade 1 and Grade X injuries, cision, taking into account limb injury extent, degree of
penetrating trauma is more likely to cause exsanguinating ischaemia, physiology, and holistic patient factors, should be
extremity or junctional haemorrhage. Immediate manage- used to manage complex extremity vascular trauma.
ment focuses on controlling haemorrhage, which may require
direct pressure, tourniquets, or haemostatic agents. Tourni- Recommendation 87
quets should be applied proximal to the wound and tightened The use of scoring systems when deciding upon limb salvage
until the bleeding stops. In junctional regions, tourniquets are or amputation for patients with extremity trauma is not
unlikely to suffice, and rapid surgical or endovascular hae- recommended.
mostasis is required. The basic principles of vascular haemor- Class Level References ToE
rhage control include proximal and distal control. Proximal IIIb B Schirò et al. (2015),425
control is usually achieved outside the zone of injury, and in Loja et al. (2018),428
junctional injuries may require entering different anatomical Elshawary (2005),422
regions. The division of ligaments and or muscles (such as Nayar et al. (2022),418
Prichayudh et al. (2009),423
inguinal and shoulder girdle musculature) may be required to Yoneda et al. (2024),419
identify and control haemorrhage. As with blunt injuries, once Gratl et al. (2023)426
the bleeding is controlled, the next priority is revascularisation
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 37

patch repair, interposition, or bypass graft. The type of

Recommendation 88
open surgical repair of vascular extremity trauma should
Multidisciplinary decision making regarding be based upon the extent of the vascular injury (ESVS
revascularisation vs. primary amputation is recommended in Grade 2, 3, or X), anatomy, physiology, and pre-existing
patients with complex extremity trauma.
patient factors. Endovascular repair is being deployed
Class Level References ToE increasingly, but remains limited to < 20% of reported
I B Schirò et al. (2015), 425
cases.432,433 In a comparative study using propensity
Loja et al. (2018),428 scored matching in 786 patients with peripheral arterial
Elshawary (2005),422 traumatic injuries using the National Readmission Data-
Nayar et al. (2022),418
Prichayudh et al. (2009),423
base, endovascular repair had a higher risk of re-
Yoneda et al. (2024),419 admission and a higher 30 day open re-operation rate
Gratl et al. (2023)426 (6% vs. 2%; p < .01), with no difference in mortality or
amputation rates.432 Other studies also found a signifi-
6.3.4. Non-occlusive extremity vascular injuries (ESVS cant risk of patency loss or re-interventions after endo-
Grade 1 and 2). Non-occlusive extremity vascular injuries vascular repair.53,434,435 In a retrospective analysis of the
pose a therapeutic dilemma to the vascular surgeon. The National Trauma Data Bank on endovascular vs. open
natural history of non-flow limiting dissection, intimal treatment of isolated superficial femoral and popliteal
injury, pseudoaneurysm, or AVF is not well understood. artery injuries (n ¼ 2 873) amputation free survival was
There is a paucity of evidence on how to manage these not different, but after multivariable logistic regression
injuries in the literature. Studies are generally of very low analysis the in hospital mortality rate was higher for
quality, so firm recommendations cannot be made. All are patients who received endovascular repair.436 Endovas-
case studies or small retrospective case series. Dennis et al. cular embolisation for bleeding from tributary arteries is
attempted to follow up 44 non-occlusive extremity arterial the most common and successful use of endovascular
injuries in 43 patients who had been treated non- approaches to extremity injury.437-439 Stent graft treat-
operatively, consisting of intimal flaps, stenosis, pseudoa- ment of larger femoropopliteal pseudoaneurysms (ESVS
neurysms, and one fistula.429 Four patients had clinical signs Grade 2 injuries) has also been described.440
within a month requiring surgery. Of the remaining pa-
tients, 23 were contactable and 17 underwent examination
and DUS. All were asymptomatic and only one had residual Recommendation 90
stenosis on ultrasound. Pan et al. reviewed 20 patients with Endovascular stent or stent graft repair may be considered as
lower limb traumatic pseudoaneurysms who were not an alternative to open repair in selected patients with
treated non-operatively; ten patients received a stent graft, extremity vascular trauma requiring operative treatment
two were coil embolised, and eight had surgical repair (ESVS Grade 2, 3, or X).
(direct repair or venous repair).430 All patients had a suc- Class Level References ToE
cessful outcome. Frykberg et al. followed up 47 patients IIb C Asmar et al. (2021),432
with 50 non-occlusive injuries; 22 had intimal flaps, 21 Butler et al. (2019),434
segmental narrowing, six pseudoaneurysms, and one Worni et al. (2013),441
AVF.431 Forty six patients were followed up for a mean of Magee et al. (2023),433
Potter et al. (2021)436
3.1 months; 89% required no treatment; five patients’
clinical signs worsened and required immediate interven-
tion.
Recommendation 91
Recommendation 89 Endovascular embolisation is recommended for active
Non-operative management with clinical and imaging follow bleeding from side branches of major arteries in patients with
up may be considered for patients with extremity non- extremity injuries.
occlusive vascular injuries (ESVS Grade 1 or 2). Class Level References ToE
Class Level References ToE I C Maleux et al. (2012),438
IIb C Dennis et al. (1998),429 D’Alessio et al. (2020),437
Pan et al. (2014),430 Cheraghali et al. (2021)439
Frykberg et al. (1991)431
6.3.6. Arterial injuries below the knee and elbow. The
6.3.5. Open or endovascular repair (ESVS Grade 2, 3, collateral supply below the elbow and knee with the
and X). Open arterial repair remains the most performed respective palmar and pedal arches reduces the need for
operative technique in patients with vascular trauma to repair of all injured vessels. Ligation of either the radial
the extremities. There are no comparative studies be- or ulnar artery in patients with an intact palmar arch is
tween the different types of open repair: primary repair, an acceptable treatment method.442 In multiple tibial
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
38 Carl Magnus Wahlgren et al.

vessel injury, there is limited evidence to guide the pre-

Recommendation 94
cise number of vessels that should be repaired although
standard teaching has been that a single intact or Intra-operative systemic heparinisation in patients with
extremity trauma may be considered on an individual basis,
repaired artery with a runoff distal to the ankle joint is
including the extent of repair, duration of interrupted blood
usually sufficient for limb salvage.443 Multiple tibial vessel flow, concomitant injuries and overall risk of bleeding, and
injury is associated with higher rates of limb loss.443e447 degree of trauma induced coagulopathy.
Rather than the overall number of tibial vessels injured Class Level References ToE
determining outcomes, one study identified that the 448
IIb C Guerrero et al. (2002),
specific artery injured was associated with limb salvage.
Maher et al. (2017)449
In a single centre study of 122 patients with single tibial
vessel injury after blunt trauma, an injured anterior tibial
artery was associated with a significantly higher ampu-
6.3.8. Extremity venous injuries. Extremity venous injuries
tation rate (6 of 17 patients, 35.3%) compared with those
in isolation or in combination with arterial injuries require
patients with either posterior tibial or peroneal injuries (3
an individualised approach to decision making regarding
of 34 patients, 8.8%; p ¼ .045).446 The adjusted OR of
repair vs. ligation. Combined arterial and venous injuries are
requiring an amputation after blunt injury to the anterior
often markers for greater trauma severity and complexity of
tibial artery alone, compared with a posterior tibial or
injury to the extremity with overall higher rates of ampu-
peroneal injury, was 22.4 (p ¼ .02).
tation, fasciotomy, and limb complications. In blunt trauma,
combined vascular injuries are often associated with
Recommendation 92
multisystem injury and therefore competing treatment
If repair is not easily achievable, ligation is recommended in priorities, e.g., control of torso haemorrhage to preserve life
isolated radial or ulnar arterial injury without evidence of over limb. Since the Vietnam conflict, there have been a
distal ischaemia.
number of studies from civilian and more recent military
Class Level References ToE conflicts, with a meta-analysis finding the risk of secondary
I C Schippers et al. (2018) 442 amputation was six times lower following venous repair
than venous ligation with no increased risk of venous
thromboembolism.408 However, to date there is no evi-
dence to definitively support one approach over another,
Recommendation 93 and patient physiology, injury burden to the limb as well as
Ligation or embolisation of an isolated infragenicular arterial other body regions, and complexity of the venous injury
injury without evidence of distal ischaemia may be must all be considered in determining the surgical strategy.
considered in patients with one of the anterior or posterior Most recently, outcomes were compared in over 300 US
tibial arteries intact and patent.
combat casualties with extremity vascular trauma and any
Class Level References ToE venous injury, between those undergoing venous repair and
IIb C Lee et al. (2024),443 venous ligation and no difference was found in vascular or limb
Dua et al. (2015),444 complications (71.1% vs. 63.9%; p ¼ .21) or amputation rate
Croman et al. (2023)445 (25.9% vs. 18.8%; p ¼ .16).451 Despite higher extremity injury
severity and more frequent fasciotomies, the authors
6.3.7. Intra-operative heparinisation. Retrospective studies concluded that concomitant venous injury was not associated
show conflicting results for systemic intra-operative hep- with poorer limb salvage or complications, and repair of
arinisation.448e450 Analysis is hampered by retrospective femoropopliteal venous injuries did not appear to influence
study designs often with selection bias. Patients receiving limb outcomes. In a civilian registry review of over 2 000
systemic intra-operative heparinisation were often less trauma patients with major venous extremity injury, those in
severely injured than those who did not.448 In a multicentre the ligation group had significantly higher rates of fasciotomy
retrospective study (n ¼ 323 patients), patency of arterial and secondary amputation and longer hospital length of stay
repair was higher after systemic intra-operative heparin- than those in the repair group (44.6% vs. 33.5%, risk ratio 1.33;
isation without increased bleeding, while data from the 6.1% vs. 3.4%, risk ratio 1.81; median [interquartile range] 11
prospective PROOVIT study (n ¼ 193 patients) found [6 e 20] days vs. 9 [5 e 17] days, respectively), although there
increased blood product use after systemic heparinisation were no significant differences in any other complications or in
without a benefit in thrombosis or limb loss.449,450 The hospital death.452 However, from the same registry, a study of
decision for systemic intra-operative heparinisation or not popliteal vascular injuries (908 combined arterial and venous
may be based upon the extent of the repair, duration of and 303 isolated venous injuries) found, in multivariable lo-
interrupted blood flow, concomitant injuries, as well as gistic regression, that ligation was not independently associ-
overall risk of bleeding and degree of trauma induced ated with in hospital amputation free survival, amputation, or
coagulopathy. death in those with isolated venous injury.453

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ESVS 2025 CPGs on the Management of Vascular Trauma 39

For simple venous injuries and or isolated venous in- ischaemia,455,460e462 with Gordon et al. advocating pro-
juries, repair is supported; but in the context of multiple phylactic fasciotomy in any limb at risk of compartment
vascular injuries, haemodynamic instability, and or other syndrome in an austere environment.462 More recent
treatment priorities to save life, then the role of venous research has cast doubt on the benefit of prophylactic
repair is diminished with temporary venous shunting and fasciotomy, however. A porcine model of prophylactic
delayed repair, or ligation as preferred surgical options. fasciotomy vs. no fasciotomy showed no functional dif-
ference after reperfusion.463 A retrospective review of 101
Recommendation 95 patients showed selective use of fasciotomy with lower
Repair of localised femoral or popliteal venous injury should
limb extremity injury spared almost half of the patients the
be considered over ligation in haemodynamically stable need for fasciotomy, with no increase in complications.464
patients. Results from the PROOVIT registry of 158 patients showed
Class Level References ToE no difference in outcomes between therapeutic and pro-
451
phylactic fasciotomy.465 Keating et al., studying 436 pa-
IIa B O’Shea et al. (2022),
Byerly et al. (2020),453
tients prospectively across 18 centres, found that index
Matsumoto et al. (2019),452 fasciotomy did not demonstrate an outcome benefit,
Manley et al. (2018),454 suggesting that careful observation and fasciotomy when
Perkins et al. (2015)408 required may reduce unnecessary surgery and
morbidity.466
6.3.9. Compartment syndrome and fasciotomy. Acute ex-
tremity compartment syndrome is a surgical emergency Recommendation 96
associated with significant morbidity if not managed Emergency four compartment fasciotomy is recommended to
expeditiously. Data from the US National Trauma Data treat traumatic post-ischaemic lower limb compartment
Bank showed that patients sustaining lower extremity syndrome.
arterial trauma required a fasciotomy in up to 42% of Class Level References ToE
cases.455 More recent US national data (Trauma Quality I B von Keudell et al. (2015),458
Improvement Program database, 2017 e 2019) found Farber et al. (2012),455
the fasciotomy rate following lower extremity vascular Bible et al. (2013),467
injury to be 6.7%, a notable reduction from previous Etemad-Rezaie et al.
reports.456 The most important tool in diagnostics is to (2022)468
maintain a high level of clinical suspicion. Patients with
classical clinical signs of compartment syndrome do not
need any further investigation and should undergo ur- 6.4. Post-operative surveillance in extremity vascular
gent fasciotomy. Ischaemia duration after arterial trauma
vascular trauma exceeding 2.5 hours presented as a Follow up and modalities vary in the literature after ex-
strong predictor for fasciotomy.457 Compartment pres- tremity vascular trauma reconstructions. These include clin-
sure is seldom measured routinely but has been used in ical examination, measurement of ABI, and imaging follow up
patients with impaired awareness or consciousness.458 with colour coded DUS, but also CTA, at various intervals
There is little consensus about the threshold value for after the procedure.469,470 DUS, CTA, MRI, or angiography
its diagnosis and treatment. have been suggested in patients who demonstrate worsening
Early fasciotomy (within eight hours after open vascular clinical manifestations and evidence of stenosis.435,471,472
repair) in patients with extremity vascular injury was asso- In the peripheral arterial disease population, a recent
ciated with a four fold lower risk of amputation (OR 0.26, Cochrane analysis showed no clear difference between DUS
95% CI 0.14 e 0.50; p < .0001) and 23% shorter hospital and standard surveillance in preventing limb amputation,
length of stay (means ratio 0.77, 95% CI 0.64 e 0.94; morbidity, and death after lower limb revascularisation.473
p ¼ .01).455 Incisions in the skin and fascia need to be long A recommendation for routine DUS surveillance of infra-
enough to make tissues loose and allow for post-operative inguinal vein grafts remains dependent on low quality evi-
swelling. The easiest and most common way to decompress dence; small number of events and high risk of bias in the
the compartments is through two incisions: anterolateral literature.474 When considering the non-invasive nature,
(to open the anterior and lateral compartments) and post- low cost, and opportunity for intervention, DUS surveillance
eromedial (to open the superficial and deep posterior may be used for follow up of lower extremity vein grafts in
compartments).458,459 Fasciotomy of the forearm is per- patients with peripheral arterial disease.
formed with decompression of the volar and lateral com- There are inadequate data demonstrating the clinical
partments and the dorsal compartment. benefit of a DUS surveillance programme after extremity
There are many studies in the literature suggesting that vascular trauma reconstructions, but it is reasonable to
delayed fasciotomy for compartment syndrome leads to assume that subgroups of patients with bypass or inter-
worse outcomes whether in trauma or acute limb position graft or stent graft might benefit from surveillance.

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
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40 Carl Magnus Wahlgren et al.

By anticipating these potential barriers and proactively

Recommendation 97
working to overcome them, healthcare providers can
Post-operative follow up with clinical examination and improve follow up compliance and patient outcomes.
duplex ultrasound one month after repair, or earlier if
abnormal findings or symptoms develop, may be considered
for patients with extremity vascular injury and vascular 7.2. Antibiotic prophylaxis after vascular trauma
reconstruction.
Apart from general trauma recommendations for the use of
Class Level References ToE peri-operative systemic antibiotics with preferred additional
IIb C Dorweiler et al. (2003),469 Gram negative coverage, there exists no evidence for or
Abu Dabrh et al. (2017),474 against the use of post-operative antibiotic prophylaxis after
Sarpe et al. (2023)473 vascular trauma. Antibiotic prophylaxis will also vary across
hospitals and countries. Therefore, considering the trauma
7. POST-OPERATIVE GENERAL CONSIDERATIONS AFTER setting diversity, injury types, and treatment methods,
VASCULAR TRAUMA individualisation of post-operative antibiotic therapy seems
Post-operative care follows the general principles of trauma reasonable. Type of antibiotics is also influenced if open
management, particularly for multiple trauma patients. fracture is present and the environment where the trauma
Vascular trauma patients should be admitted to a unit took place. A prospective single centre study recommended
where the patient can be evaluated regularly, especially for the use of prophylactic antibiotics for the first 24 hours
the first 24 e 48 hours. Communication between the after stent graft treatment of penetrating carotid artery
operative and the intensive care unit team about operative injuries, and an extremity vascular trauma study suggested
findings and the post-operative plan is paramount to pre- continuing the use of pre-operative prophylactic antibiotics
vent any possible complications. for 24 hours post-operatively.167,475
Vascular status post injury and repair need to be
assessed by physical examination, including pulse exami- 7.3. Post-operative antithrombotic therapy
nation and Doppler, while colour coded DUS and CTA can The literature on antithrombotic therapy after vascular
be used on a selective basis. Coagulation status and repair in patients with peripheral atherosclerotic disease
rhabdomyolysis are monitored with laboratory blood cannot be generalised to most patients with arterial or
tests. Extremities are evaluated clinically for development venous repair for extremity vascular trauma.476 There is
of a compartment syndrome that may require urgent limited literature on post-operative antithrombotic medi-
fasciotomy. Compression stockings and intermittent cation.477 According to a meta-analysis by Khan et al.,
pneumatic compression devices to prevent deep venous anticoagulation may have some benefit in vascular trauma
thrombosis and leg swelling as well as early physio- surgery of the peripheral extremity to reduce intra- and
therapy for functional impairment have been well post-operative complications.477 They found no increase in
demonstrated in the trauma setting. negative outcomes with anticoagulation use.477 In contrast,
a recent report using the American College of Surgeons
7.1. Post-operative surveillance Trauma Quality Improvement Program found that post-
Optimal follow up and surveillance after vascular injury operative administration of unfractionated heparin was
remains controversial. There is no evidence to support associated with increased bleeding complications in 4 379
routine surveillance in all patients, however it is reasonable patients with peripheral arterial injuries.478 In a prospective
to assume that subgroups of patients might benefit from observational multicentre study, the influence of no
surveillance. The modification of guidelines from athero- antithrombotic vs. different regimens of antithrombotic
sclerotic vascular disease intervention protocols would therapy was investigated in 373 patients with arterial in-
seem ideal, but even in that setting controversy regarding juries repaired with a vein graft. No difference was seen for
optimal surveillance exists, and most patients with vascular in hospital operative re-intervention or thrombosis, but
trauma do not have a cardiovascular disease burden.54 For more long term use of antithrombotics was beyond the
specific surveillance recommendations, please see each scope of the study.479 Also, in a small retrospective
chapter in these vascular trauma guidelines. comparative matched analysis, no difference regarding
Following up with trauma patients presents several bleeding or thrombosis was seen with the use of aspirin or
challenges that may impact recovery and long term intravenous heparin at therapeutic dose vs. no antith-
outcome. Non-compliance with post-operative surveillance rombotics.480 While there is a concern for post-operative
remains an issue after open or endovascular repair. haemorrhage, there is also a competing risk of thrombosis
Other challenges may include involvement of multiple of the reconstruction, and practices vary widely.479 An
healthcare providers and specialists, rehabilitation adher- individualised post-operative antithrombotic strategy has
ence, socio-economic barriers, psychological and emotional been advised. Patient risk factors, including bleeding and
reactions, as well as cultural and language differences. thrombotic risk as well as complexity of vascular repair,
Addressing these challenges requires a multidisciplinary need to be assessed when deciding an antithrombotic
approach and a commitment to patient centred health care. regimen.

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Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 41

selective individualised management strategy is safe.486e488

Recommendation 98
Minor lesions (ESVS Grade 1 and 2) can be treated with
Post-operative single antiplatelet therapy may be considered antiplatelet or anticoagulant drugs.486e488 There is no
for patients with vascular trauma who have undergone open
strong evidence to recommend a specific antithrombotic
or endovascular repair.
agent. The most recent meta-analysis was in favour of using
Class Level References ToE a single antiplatelet agent but excluded all studies in pae-
IIb C Khan et al. (2020), 477
diatric patients (< 18 years of age).204 In a small retro-
Stonko et al. (2023)479 spective study with patients aged < 10 years diagnosed
with BCVI, there were no observed differences in the rate of
haemorrhagic complications between anticoagulation and
8. PAEDIATRIC VASCULAR TRAUMA antiplatelet therapy, but a non-significant better rate of
healing on follow up imaging in children who underwent
8.1. General considerations antiplatelet therapy.489 Enlarging pseudoaneurysm or active
Traumatic vascular injuries in children are relatively bleeding (ESVS Grade 2 or 3) can be approached by em-
rare.13,481 There is a general lack of clinical evidence, which bolisation or open repair.488,490 Follow up must be long
makes it difficult to make firm management recommenda- term to ensure effective remodelling of the artery.491 Pae-
tions. The text will try to provide the best available data to diatric oropharyngeal injuries are a rare cause of ICA injury
guide management. Paediatric vascular trauma poses chal- with bleeding, dissection, thrombosis, or embolisation, and
lenges because of smaller arteries that are prone to vaso- have only been described in a limited number of case series.
spasm, small intravascular volume, the need for future
vessel growth (longitudinal and circumferential), and Recommendation 100
consideration of long term durability.6 Children also possess
Early antithrombotic therapy is recommended for children
an effective compensatory ability that sometimes justifies a with blunt, low grade carotid artery injury (ESVS Grade 1 or
non-operative management approach. 2).
For diagnostic investigations in children, CTA has been Class Level References
the most reported imaging modality performed, with high
I C Consensus
sensitivity and specificity both for blunt and penetrating
vascular trauma.6,91,95

Recommendation 99
8.3. Thoracic aortic injury
Computed tomography angiography is recommended as the BTAI in children is rare. Among 26 940 children with a blunt
first line investigation to identify or rule out vascular injury mechanism of injury, 34 children (0.1%) sustained a thoracic
in haemodynamically stable paediatric trauma patients. aortic injury, 14 (41%) of whom died.492 Older children
Class Level References ToE involved in a motor vehicle collision with severe head, torso,
95 and lower extremity injuries are a group at high risk of BTAI. As
I C Patterson et al. (2012),
Moody et al. (2024)6 in adults, physiology and concomitant injuries on admission
can jeopardise open repair, while endovascular repair is
complicated by the small diameter of the aorta and or access
Repair of traumatic vessel injury in children, particularly vessels and hostile configuration of the aortic arch. Long term
infants, is challenging regarding the choice of conduit. There results are not available. Regardless of these disadvantages,
is no high quality evidence to recommend autologous or TEVAR is accepted as a lifesaving or bridging procedure (ESVS
synthetic graft material, but vein may be more suitable for Grade 2 and 3). Published experience of TEVAR for BTAI in
small calibre vessels in children. Interrupted sutures to children is limited. Hosn et al. identified fewer than 20 patients
avoid post-operative stenosis due to the purse string effect younger than 18 years old treated by endovascular repair.493
and to prevent narrowing of the anastomosis associated Raulli et al. analysed the American National Trauma Data
with growth have been described.482 The risk of vein graft Bank and found that adult patients had significantly higher
dilatation is expected over time. Again, if rapid restoration rates of TEVAR than children (3% children, 25.2% adolescent,
of flow is needed and there is a vessel diameter mismatch, a and 29.2% adult patients) and that children were most likely to
synthetic interposition graft may be the best solution, with receive non-operative management (94% children, 67.9%
some advocating sewing the graft with some slack to adolescent, and 64.8% adult patients).494 An initial non-
accommodate growth. Also, the experience with stent graft operative approach to small pseudoaneurysms (ESVS Grade
repair, e.g., in the aorta, and sizing is limited. 2) seems reasonable in children. Midterm complications faced
in children and young individuals are related to oversizing and
8.2. Neck vessel injuries bird beak causing collapse, migration, stenosis, or occlusion of
The incidence of BCVI may be as high in children as in the stent graft.495e497 In an acute setting, stenosis with or
adults.192,483e485 There are few data on the management of without complete thrombosis and collapse are the most
vascular neck injuries in children as well as the interpreta- devastating complications presenting with sudden hyperten-
tion of CTA imaging findings. Small studies suggest that a sion, claudication, spinal cord ischaemia, acute renal
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
42 Carl Magnus Wahlgren et al.

impairment, and visceral malperfusion.379,498 In the long term, repair or repair technique. Interrupted sutures are mentioned,
chronic effects of the stent graft on the heart and vasculature preventing narrowing of the anastomosis that might occur
could be an issue (myocardial injury, aortic remodelling with with the growth of the patient.482 Long term complications are
elongation of the arch and aortic stiffness) and will need rare after repair for extremity vascular trauma in children, and
further analysis. Prevention or control of all these complica- even in cases where bypass grafts occlude no clinical conse-
tions is needed by continuous monitoring and timely re- quences occurred according to a recent systematic review.6
intervention or conversion to open repair when necessary. Also, no incidents of length discrepancy were found.
Patients and parents should be informed of the need for long
term follow up. Recommendation 103
Clinical vascular examination in line with adult guidance is
Recommendation 101 recommended in all children with upper or lower extremity
Endovascular stent graft repair should be considered as the trauma to identify potential haemorrhagic or ischaemic
first line operative treatment for children with blunt thoracic vascular injuries.
aortic injury (ESVS Grade 2 or 3) and appropriate anatomy. Class Level References
Class Level References ToE I C Consensus
493
IIa C Hosn et al. (2017),
Raulli et al. (2023)494
Supracondylar humeral fracture in children is the most
common fracture in the elbow, with injury to the brachial
8.4. Abdominal vascular injuries artery occurring in approximately 8 e 12%.501 Closed
From a National Trauma Data Bank study of vascular injuries reduction and fixation of the fracture should be the priority
in the paediatric population (n ¼ 1 138) by Barmparas et al., in all pulseless supracondylar humeral fractures, and if there
abdominal vascular injuries (AVIs), the second most remains a poorly perfused pale hand immediate surgical
commonly injured region, were reported in 24.2%.13 CTA is exploration of the artery is indicated. There is continued
the gold standard in diagnosing AVI with 100% sensitivity, support in the literature that a child with a pink pulseless
93% specificity, 85% positive predictive value, and 100% hand post-fracture reduction can be managed expectantly
negative predictive value.91,340,499 The majority of abdominal unless additional signs of vascular compromise develop, in
trauma in children is managed non-operatively, but haemo- which case exploration should be undertaken.501-503
dynamic instability despite maximum resuscitative efforts
mandates emergency laparotomy.500 Management strate- Recommendation 104
gies for paediatric AVI parallels the adult trauma population. Non-operative management should be considered in a child
Open and endovascular treatment modalities are challenged with a pink and warm, but pulseless, hand post-
by the size of the vessel encountered, and appropriate ac- supracondylar humeral fracture reduction with close
commodations in graft and device selection are required. observation for the development of acute ischaemia.
Caution should be taken to prevent vessel narrowing due to Class Level References ToE
growth. This may include bevelled anastomosis with inter- IIa C Delniotis et al. (2019), 501

rupted sutures as well as using a slightly longer Dacron graft. Goh et al. (2024),502
Griffin et al. (2008)503
Recommendation 102
Immediate surgical exploration and bleeding control are
Several specialists including vascular surgeons, alongside
recommended for children in shock with ongoing
haemorrhage and suspicion of major abdominal vascular paediatric surgeons, general, plastic and orthopaedic sur-
injury. geons, and interventional radiologists, play an important
Class Level References
role in the multidisciplinary management of children with
extremity vascular injuries.
I C Consensus

8.6. Post-operative considerations

8.5. Extremity vascular trauma A standard protocol for antithrombotic therapy does not exist
The extremity is the dominating anatomic location in paedi- for paediatric patients after vascular trauma. Antiplatelet
atric vascular trauma. A recent systematic review found that therapy using aspirin or clopidogrel and weight based dosing
the upper extremity is more prone to vascular trauma in for the administration of LMWH have been suggested.489
children than the lower extremity.6 In young children, blunt Follow up recommendations in some studies consisted of
extremity injuries are most common (road traffic collision, fall, clinical examination and colour coded DUS after vascular
sport related), with penetrating extremity injury (glass, gun- repair and for graft surveillance in children treated for arterial
shot, or stab wound) becoming more prevalent in older chil- ischaemia following trauma.482,504 Surveillance CTA should be
dren. Most often primary repair can be performed. avoided in children if not absolutely necessary. There is little
Unfortunately, there are no comparative studies on the type of evidence regarding the frequency of follow up.

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 43

society. There are now more networks and multicentre in-

Recommendation 105
stitutions prioritising trauma research and conducting clinical
Post-operative follow up with clinical examination and trials. Artificial intelligence may have an increased role in the
duplex ultrasound one month after repair, or earlier if
future. There are, for example, two reports showing that ma-
abnormal findings or symptoms develop, may be considered
for children with extremity vascular injury reconstructed chine learning may be able to accurately predict the outcome
with bypass or interposition graft. of limb salvage.427,505
Class Level References
There are several unanswered questions in vascular
trauma identified by the GWC as being research priorities
IIb C Consensus
for the future. These involve situations where there were
either no data or conflicting evidence that did not allow
9. GAPS IN EVIDENCE/RECOMMENDATIONS FOR FUTURE recommendations to be made.
RESEARCH All these issues contribute to the broad spectrum of gaps
In general, trauma research needs large scale prospective in vascular trauma evidence, of which the most relevant are
studies and RCTs to evaluate management strategies and to listed in Table 12.
deliver new therapeutic interventions. Due to the paucity of
literature on vascular trauma, recommendation on the optimal 10. PATIENTS’ PERSPECTIVES
management strategy in some areas is left to the discretion of
the operating surgeon to decide based upon the extent of the 10.1. Introduction
vascular injury, physiological status of the patient, concurrent Vascular trauma, or an injury to a blood vessel, can happen
injuries, contamination, and external circumstances such as to anyone. Arteries and veins are the blood vessels that
mass casualty incidents. Historically, a relatively small fraction transport blood around the body. Arteries carry blood away
of health research expenditure has been spent on trauma from the heart, while veins return it. Injury to the blood
research in relation to the significant burden of disease on vessels by a tear, crush, or puncture can lead to bleeding

Table 12. Main evidence gaps in the management of patients with vascular trauma.

General
European vascular trauma epidemiology data are scarce
The optimal duration of temporary intravascular shunts is not yet defined
Selection of patients who may benefit from resuscitative endovascular balloon occlusion needs definition
There are issues of long term patency and durability after endovascular stents and stent grafts
Hybrid operating room and improved outcome of vascular trauma
The role of graft material such as bovine or human acellular matrix grafts for arterial reconstruction
Assessment of timing of anticoagulant delivery and doses after vascular trauma
Neck
Antithrombotic regimens and duration after blunt or penetrating carotid artery injury
Comparison between antithrombotic treatments for BCVI; aspirin vs. low molecular weight heparin
Follow up imaging intervals after BCVI
Thoracic
The role of non-operative management of ESVS Grade I and small grade II BTAI
The role and timing of TEVAR for BTAI in patients with associated traumatic brain injury
There is a need to define specific risk factors for early aortic rupture in patients with BTAI, and the ideal timing for operative intervention
The long term durability of endovascular devices used for BTAI treatment remains to be determined
Graft sizing and graft use in paediatric BTAI patients, or patients with small aortic diameters, are inadequately studied
Imaging surveillance protocols need to be defined in patients treated with TEVAR for BTAI
Abdominal
Optimal management strategy for mesenteric vessel injury
Renal ischaemia time after trauma and kidney salvage
Optimal management strategy for renal vessel injuries
A contemporary prospective multicentre study is needed to compare ligation vs. repair of IVC injuries
Extremity
Decision to proceed to revascularisation or amputation in complex extremity vascular trauma
Comparative studies of open or endovascular repair for extremity arterial trauma, and data on long term follow up
Optimal management of occult vascular injuries
Operative strategy for extremity venous injuries
Post-operative surveillance and antithrombotic regimen after arterial reconstruction
Miscellaneous
Definition of adequate clinical trial endpoints in vascular trauma
BCVI ¼ blunt cervical vascular injury; ESVS ¼ European Society for Vascular Surgery; BTAI ¼ blunt thoracic aortic injury; TEVAR ¼ thoracic
endovascular aortic repair; IVC ¼ inferior vena cava.

Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
44 Carl Magnus Wahlgren et al.

 Apply pressure to stop the bleeding by pushing,

preferably using a clean cloth, directly on the wound
with both hands (Fig. 6).
 While waiting for emergency help to arrive, try to keep
the injured person warm and from moving.
10.4. Management
Up to half of all trauma deaths within the first 24 hours after
injury are attributable to major bleeding. The priority in
vascular trauma is therefore to control bleeding, and the
second priority is to restore circulation to the brain or to or-
gans, e.g., in the abdomen or in the leg to prevent amputation.
Minor vascular injuries can be managed with non-operative
treatment, including blood thinner medication. Sometimes an
injured vessel can just simply be tied off during operation.
However, major vascular injuries usually require surgical repair
with sutures or with a graft (vein or prosthetic artificial graft).
Minimally invasive techniques (endovascular techniques) can
be an option for some vascular injuries to plug the vessel or to
use a stent graft (a metal tube covered with polyester) to cover
the injury and keep the vessel open.

10.5. Follow up
Each person with a vascular injury and path to recovery is
Figure 5. Injury to blood vessel with bleeding. different.When it is time to leave the hospital, there should be
an after hospital plan of care, including medications and follow
(Fig. 5) but also formation of blood clots that can cause up appointments. Some people may be discharged directly
blockage of blood flow. The most common injuries are to home. However, many people need specialised care after they
arteries and veins of the legs and arms. leave the hospital, which may include physical therapy and
Vascular trauma in civilian practice most commonly arises rehabilitation. There may also be other associated injuries that
from fall, traffic accidents, and knife and gun violence. require further care. Going through a traumatic injury may
Vascular trauma is managed by multidisciplinary teams, cause a range of strong emotions, sometimes requiring pro-
including vascular and trauma or general surgeons as well fessional help. A delayed emotional reaction to trauma may
as anaesthetists, orthopaedic surgeons, and interventional occur as well. It is important to have regular follow up visits
radiologists. A referral to a trauma centre or hospital with with the physician and the hospital services in charge. Some-
this multispecialty expertise is recommended to treat times imaging will be carried out, such as ultrasound or CT, to
complex vascular injuries. determine the performance of the vascular repair.

10.2. Symptoms and diagnosis of vascular trauma 10.6. Outcome

Blood vessel injuries can cause a variety of symptoms Vascular trauma is a serious condition with risk of life and
depending on the body location. Symptoms include severe limb loss. Modern trauma care in specialised hospitals with
bleeding or swelling called haematoma, but also signs of multidisciplinary trauma teams improves patient outcomes.
decreased circulation in the limbs including pain, pallor, and loss
of pulses. A vascular injury can be diagnosed by physical ex-
amination alone, but most commonly in the case of multiple
injuries diagnostic imaging is needed with CT scanning in
hospital.

10.3. How to stop severe bleeding?

Severe bleeding is the major cause of preventable death
from trauma. A person with uncontrolled bleeding can die
within minutes, so it is important to quickly stop blood loss.
For severe bleeding, take the following first aid steps:

 Call the local medical emergency services.

 Find the bleeding injury by open or removing clothing if
Figure 6. Apply pressure to stop the bleeding.
needed.
Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018
ESVS 2025 CPGs on the Management of Vascular Trauma 45

ACKNOWLEDGEMENTS and Division of Cardiovascular Sciences, School of Medical

Vascular surgeons in training that contributed to these Sciences, Manchester Academic Health Science Centre, The
guidelines: Dr Manik Chana, UK; Dr William Cullen, UK; University of Manchester, Manchester, UK; Jonathan R.
Dr Davina Daudu, Australia; Dr Lucie Derycke, France; Dr Boyle, Cambridge University Hospitals NHS Trust and
Megan Fox, Ireland; Dr Aurélien Hostalrich, France; Dr Department of Surgery, University of Cambridge, Cam-
Thomas Mesnard, France; Dr Nick Moody, UK; Dr Alexandre bridge, UK; Raphaël Coscas, Ambroise Paré University Hos-
Pouhin, France; Dr Prashanth Ramaraj, UK; Dr Hannah pital, AP-HP, Boulogne-Billancourt, France; Nuno V. Dias,
O’Reilly, UK; Dr Alessandro Serafini, Italy; Dr Matt Spread- Department of Clinical Sciences Malmö, Lund University and
bury, Norway; Dr David Strachan, UK; Dr Amy Walter, UK; Vascular Centre Malmö, Skåne University Hospital, Malmö,
and Dr Jade Whing, UK. Illustrations: Mats Ceder, Sweden. Sweden; Barend M.E. Mees, Maastricht UMCþ, Maastricht,
the Netherlands; Santi Trimarchi, Department of Clinical
APPENDIX A. SUPPLEMENTARY DATA and Community Sciences, University of Milan, Milan, Italy,
and Cardiac Thoracic Vascular Department, Fondazione
Supplementary data to this article can be found online at
IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan,
https://doi.org/10.1016/j.ejvs.2024.12.018.
Italy; Christopher P. Twine, North Bristol NHS Trust and
University of Bristol, Bristol, UK; Isabelle Van Herzeele,
APPENDIX B. AUTHORS’ AFFILIATIONS
Department of Thoracic and Vascular Surgery, Ghent Uni-
Writing Committee versity Hospital, Ghent, Belgium; Anders Wanhainen,
Carl Magnus Wahlgren (Chair), Karolinska Institutet, Stock- Department of Surgical Sciences, Vascular Surgery, Uppsala
holm, and Department of Vascular Surgery, Karolinska University, Uppsala, Sweden, and Department of Di-
University Hospital, Sweden; Karim Brohi (Co-Chair), Queen agnostics and Intervention, Surgery, Umeå University,
Mary University of London, London, UK; Jean-Baptiste Ricco Umeå, Sweden.
(Co-Chair), University of Poitiers, Medical School, Poitiers,
France; Christopher Aylwin, Centre for Trauma Sciences, Document Reviewers
Blizard Institute, Queen Mary University of London, London, Paul Blair, Royal Victoria Hospital, Belfast, Northern Ireland,
UK; Ross A. Davenport, Royal London Major Trauma Centre, UK; Ian D.S. Civil, Auckland City Hospital, Auckland, New
Barts Health, London, UK and Centre for Trauma Sciences, Zealand and University of Auckland, Faculty of Medical and
Blizard Institute Queen Mary University of London, London, Health Sciences, Auckland, New Zealand; Michael Engel-
UK; Lazar B. Davidovic, Faculty of Medicine, University of hardt, Department of Vascular and Endovascular Surgery,
Belgrade Clinic for Vascular and Endovascular Surgery, Military Hospital Ulm, Ulm, Germany, Erica L. Mitchell,
University Clinical Centre of Serbia, Belgrade, Serbia; Joseph University of Tennessee Health and Science University,
J. DuBose, University of Texas e Austin, Austin, TX, USA; Memphis, TN, USA; Gabriele Piffaretti, Vascular Surgery,
Christine Gaarder, Department of Traumatology, Oslo Uni- Department of Medicine and Surgery, University of Insubria
versity Hospital and Institute of Clinical Medicine, University School of Medicine, Varese, Italy; Sabine Wipper, Depart-
of Oslo, Oslo, Norway; Catherine Heim, Anaesthetics ment of Vascular Surgery, Medical University Innsbruck,
Department, University Hospital, Lausanne, Switzerland; Innsbruck, Austria.
Vincent Jongkind, Amsterdam UMC, Amsterdam, the
Netherlands; Joakim Jørgensen, Departments of Trauma-
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Please cite this article as: Wahlgren CM et al., European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular
Trauma, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.12.018